Forms

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New providers meeting the following criteria must enroll using the Provider Enrollment Portal (PEP):
- 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
If you do not meet the criteria above, use the enrollment forms below designated for existing providers only.
Enrollment Forms
| Title | Last Modified |
|---|---|
| Title | Last Modified |
| Standard Provider Enrollment Form (Existing Providers Only) | 02/01/2010 |
| Standard Provider Enrollment Form - Attachment A (Existing Providers Only) | 02/01/2010 |
| Change of Medicaid Provider Information Form | 03/03/2009 |
| Dispensing Provider Addendum | 02/01/2010 |
| Electronic Remittance (835) Authorization Form | 11/03/2008 |
| Federally Qualified Health Center Provider Enrollment Form (Existing Providers Only) | 02/01/2010 |
| Home Infusion Therapy Provider Addendum | 11/03/2008 |
| Information Submission Agreements | |
| Mental Health Physician Clinic Provider Addendum | 02/01/2010 |
| Physician Assistant Provider Addendum | 05/26/2009 |
| Physician Provider Addendum | 02/01/2010 |
| Residential Psychiatric Treatment Center Provider Addendum | 02/01/2010 |
| Residential Psychiatric Treatment Center Provider Letter of Attestation | 05/26/2009 |
| Retail Pharmacy Provider Addendum | 02/01/2010 |
| School Based Service Provider Addendum | 02/01/2010 |
Information Submission Agreement Forms
| Title | Last Modified |
|---|---|
| Billing Agent Information Submission Agreement | 07/26/2007 |
| Billing Agent Information Submission Agreement Instructions | 08/19/2009 |
| Electronic Remittance (835) Authorization Form | 11/03/2008 |
| Provider Information Submission Agreement | 08/19/2009 |
| Provider Information Submission Agreement Instructions | 08/19/2009 |
Pharmacy Forms
| Title | Last Modified |
|---|---|
| General Medication Prior Authorization Form | 06/07/2007 |
| Synagis Prior Authorization Request Form | 09/08/2009 |
| More State of Alaska Health Care Services Pharmacy Medication Prior Authorization Forms. |
Other Forms
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