Alaska Pregnancy Verification Form

Use this form in the State of Alaska for Verification of your Pregnancy.

Alaska Pregnancy Verification Form

Text Version of this Form

STATE OF ALASKA
DEPARTMENT OF HEALTH & SOCIAL SERVICES
DIVISION OF PUBLIC ASSISTANCE

PREGNANCY VERIFICATION

THIS IS TO VERIFY THAT
(Please print patient’s name)

IS PREGNANT WITH AN ESTIMATED DELIVERY DATE OF .

MEDICAL PROVIDER SIGNATURE:
(Doctor, Nurse, Medical Practitioner, etc.)

PRINTED NAME:

TITLE:

DATE:

TO MEDICAL PROVIDER: PLEASE COMPLETE THIS FORM AND RETURN IT
TO YOUR PATIENT, OR SEND THE COMPLETED FORM TO THE DIVISION
OF PUBLIC ASSISTANCE OFFICE.

GEN 30 06-3710 (10/88)