Alaska pays Interim Assistance to Adult Public Assistance applicants while their SSI disability claim is pending, and this one-page form is the medical piece of that decision. The provider checks which listed severe impairments the person has, gives diagnoses and expected duration, and attaches supporting records. The Division of Public Assistance compares the diagnoses with Social Security's listings.
A licensed medical provider, such as a physician, PA, APRN or psychologist, completes everything after the applicant's name and signs. The applicant handles the Adult Public Assistance application and release of information separately.
Download the current version from the source each time; forms change without notice.
Preliminary Examination for Interim Assistance
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Cash help from the Division of Public Assistance for Adult Public Assistance applicants while their SSI disability application is pending. The AD 2 gives DPA the medical information it needs to decide: which listed severe impairments apply, the diagnoses, expected duration and the supporting medical records.
The form states that if the patient cannot pay for an exam or tests needed solely to complete it, Medicaid may cover them. It does not set a fee for the provider's time in completing the form itself.
No. The form states that completing it does not by itself establish disability. DPA compares the diagnoses and supporting records with Social Security's listings before deciding whether the person qualifies for Interim Assistance.