Group Provider Enrollment (Affiliation) Page

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You use the Group Affiliation page to add or edit a group provider's affiliation to individual providers to the enrollment application.

Field	Description
To add a new individual practitioner, click Add Affiliation. Existing affiliations, if any, are displayed in a table. To edit, in the Affiliations table, click the appropriate row. After changing or adding an individual practitioner, on the Affiliation action bar, click Save.
Name of Affiliate	Name of individual practitioner (affiliate).
Alaska Medical Assistance Provider ID Type	The affiliate's type of Medicaid ID. Example: NPI
Alaska Medical Assistance Provider ID	Alaska Medicaid provider number.
Affiliation Type	Type of affiliation to the group. Example: Hospital to Hospital-Based Provider
Effective Date of Affiliation	Date the group affiliation began. Format: MM/DD/YYYY, or click the calendar to select a date.
Zip Code	The affiliate's zip code.

Version as of 6/30/2015.