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.

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

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.

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

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