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

See the Enrollment page.

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 02/03/2012
Provider Information Submission Agreement 08/19/2009
Provider Information Submission Agreement Instructions 08/19/2009

Pharmacy Forms

Title Last Modified
Botulinum Toxin Prior Authorization Request Form 05/14/2012
General Medication Prior Authorization Request Form 07/01/2011
More State of Alaska Health Care Services Pharmacy Medication Prior Authorization Forms.  

Service Authorization Forms

Title Last Modified
Title Last Modified
Certificate of Medical Necessity Form 12/24/2012
Certificate of Medical Necessity Form - Incontinence Supplies 03/26/2013
Certificate to Request Funds for Abortion 11/01/2012
Community Behavioral Health Clinic Service Authorization Request Effective 07/01/12 DOS 11/09/2012
Community Behavioral Health Clinic Service Authorization Request Effective 12/1/11 DOS 12/01/2011
Community Mental Health Clinic Prior Authorization Request Form Effective 1/1/10 DOS (*) 03/12/2010
Consent for Sterilization Form 10/01/2012
Hysterectomy Consent Form 12/01/2009
Mental Health Physician Clinic Service Authorization Request Effective 07/01/12 DOS 11/09/2012
Mental Health Physician Clinic Service Authorization Request Effective 12/1/11 DOS 12/01/2011
Mental Health Physician Clinic Prior Authorization Form Effective 1/1/10 DOS (*) 03/12/2010
Prior Authorization Request Form (See Service Authorization Request Form ) 03/13/2012
Service Authorization Request Form 03/13/2012
Substance Abuse Prior Authorization Form Effective 1/1/10 DOS (*) 03/12/2010
Synagis Prior Authorization Request Form (fill-in online version) 09/14/2012

Other Forms

Title Last Modified
Title Last Modified
Adjustment/Void Form 06/04/2012
Air Ambulance Flight Summary 02/28/2012
Attachment Fax Cover Sheet 03/02/2012
Care Management Program Provider Statement 03/02/2012
Check Amount and Claim Status Inquiry Form 03/02/2012
Complaint Form (Suspected Fraud or Abuse) 03/02/2012
Handicapping Labiolingual Deviation (HLD) Index Report 03/02/2012
Health Care Forms and Billing Manuals Request Form 03/27/2012
Pay-To Election Form 03/02/2012
Provider Appeals Form 03/02/2012
Recipient Eligibility Inquiry Form - General 03/02/2012
Recipient Eligibility Inquiry Form - Vision 03/02/2012
Suspected Fraud and Abuse Form 03/02/2012
TPL Avoidance Request Form 11/03/2008
Warrant Status Change Request 03/02/2012