Enrollment Applications

Before submitting claims to the Alaska Medical Assistance Program, you must first enroll as a Medical Assistance Provider using the Provider Enrollment Portal (PEP). This includes:

• Providers not currently enrolled in the Alaska Medical Assistance Program
• Providers that are currently enrolled, but who wish to enroll as a different type of provider using their current tax ID
• Providers that wish to enroll as the same provider type but with a new tax ID

Additions or changes to existing provider records can be done by downloading the appropriate form.

A general overview of PEP can be found here.

Click here to begin processing a new enrollment. Online training is available to provide additional guidance. Enrollment information may also be obtained by calling Xerox, Provider Services Department at (907) 644-6800, option 2, within Anchorage or outside of Alaska and (800) 770-5650 from other Alaska locations. Application forms may also be obtained by downloading the appropriate form from the list presented here.

Please print and complete the appropriate enrollment form and mail to:

Provider Enrollment
P.O. Box 240808
Anchorage, Alaska 99524-0808

New Providers

Title	Last Modified
Title	Last Modified
Dispensing Provider Addendum	03/02/2012
Electronic Remittance (835) Authorization Form	03/02/2012
Home Infusion Therapy Provider Addendum	03/02/2012
Information Submission Agreements
Mental Health Physician Clinic Provider Addendum	03/02/2012
Physician Assistant Provider Addendum	03/02/2012
Physician Provider Addendum	03/02/2012
Provider Agreement	03/02/2012
Provider Enrollment Glossary	08/02/2010
Provider Enrollment Portal (PEP) Overview	03/30/2012
Provider Enrollment Taxonomy Reference	08/02/2010
Provider Type Reference	08/02/2010
Residential Psychiatric Treatment Center Provider Addendum	02/03/2012
Residential Psychiatric Treatment Center Provider Letter of Attestation	03/02/2012
Retail Pharmacy Provider Addendum	03/02/2012
School-Based Service Provider Addendum	03/08/2012

Enrollment Documents

Title	Last Modified
Enrollment Instructions for Community Health Aides/Practitioners	10/24/2011
Enrollment Instructions for Dental Health Aides/Therapists	10/24/2011

Existing Providers

Title	Last Modified
Title	Last Modified
Change of Medicaid Provider Information Form	03/02/2012
DHA/T & CHAP Change of Medicaid Provider Information Form	03/27/2012
Dispensing Provider Addendum	02/01/2010
Electronic Remittance (835) Authorization Form	03/02/2012
Enrolled Provider Social Security Number Submission	03/02/2012
NPI Enrollment Requirements	08/13/2009
Home Infusion Therapy Provider Addendum	03/02/2012
Information Submission Agreements
Mental Health Physician Clinic Provider Addendum	03/02/2012
Personal Care Assistant Change of Provider Information Form	03/02/2012
Personal Care Assistant Change of Info Instructions	06/27/2011
Physician Assistant Provider Addendum	03/02/2012
Physician Provider Addendum	03/02/2012
Provider Agreement	03/02/2012
Residential Psychiatric Treatment Center Provider Addendum	03/02/2012
Residential Psychiatric Treatment Center Provider Letter of Attestation	03/02/2012
Retail Pharmacy Provider Addendum	03/02/2012
School-Based Service Provider Addendum	03/08/2012
Standard Provider Enrollment Form	03/02/2012
Standard Provider Enrollment Form - Attachment A