Individual Provider Enrollment (Identifying Information) Page

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You use the Identifying Information page to add an individual provider's identifying information to the enrollment application.

The Identifying Information page for Individual Provider Enrollment contains the following panels:

Provider Type Field

Field	Description
Provider Type	The provider classification. Based on type of service being provided. Examples: Dentist, Physician, Optician, Dietician

Field

Description

Provider Type

The provider classification. Based on type of service being provided.

Examples: Dentist, Physician, Optician, Dietician

Identifying Information- Section 1 Fields

Field	Description
Last Name	Provider's last name.
First Name	Provider's first name.
MI	Provider's middle initial.
Suffix	Provider's suffix. Examples: Sr, Jr, etc.
Title	Provider's title. Examples: MD, OD
Date of Birth	Provider's date of birth.
Gender	Gender of the provider (male or female).
May gender information be shared with members?	Select Yes or No to indicate if you want your gender information shared with Medicaid members or not.
Country of Birth	Provider's country of birth.
State	Provider's state. (If country of birth, USA)
Requested Enrollment Begin Date	The requested enrollment start date. Enrollment can be requested 12 months retroactively from enrollment submission date.
SSN/ITIN	The Social Security number for the individual provider. Your SSN / ITIN will be linked to your Alaska Medical Assistance Provider number. All claims paid to your Alaska Medical Assistance Provider number will be submitted as income under your SSN / ITIN to the IRS. If you plan to bill using your Employer Identification Number (FEIN), the group through whom you plan to bill must complete a separate application and list you as an affiliated member, which links you to their FEIN.
Do you bill claims that will be paid and reported under your SSN / ITIN?	Select Yes or No to indicate whether you bill claims that are paid and reported under your SSN/ITIN. If Yes, enter a FEIN.
FEIN	The Federal Employer Identification Number.

Field

Description

Last Name

Provider's last name.

First Name

Provider's first name.

Provider's middle initial.

Suffix

Provider's suffix.

Examples: Sr, Jr, etc.

Title

Provider's title.

Examples: MD, OD

Date of Birth

Provider's date of birth.

Gender

Gender of the provider (male or female).

May gender information be shared with members?

Select Yes or No to indicate if you want your gender information shared with Medicaid members or not.

Country of Birth

Provider's country of birth.

State

Provider's state. (If country of birth, USA)

Requested Enrollment Begin Date

The requested enrollment start date. Enrollment can be requested 12 months retroactively from enrollment submission date.

SSN/ITIN

The Social Security number for the individual provider. Your SSN / ITIN will be linked to your Alaska Medical Assistance Provider number. All claims paid to your Alaska Medical Assistance Provider number will be submitted as income under your SSN / ITIN to the IRS. If you plan to bill using your Employer Identification Number (FEIN), the group through whom you plan to bill must complete a separate application and list you as an affiliated member, which links you to their FEIN.

Do you bill claims that will be paid and reported under your SSN / ITIN?

Select Yes or No to indicate whether you bill claims that are paid and reported under your SSN/ITIN. If Yes, enter a FEIN.

FEIN

The Federal Employer Identification Number.

Previous Medicaid Provider Information Fields

Field	Description
Were you previously enrolled in the Alaska Medical Assistance Program?	Select Yes or No to indicate if the individual was previously enrolled as a Medicaid provider in Alaska. If Yes, please enter the AK Medical Assistance Provider #.
Alaska Medical Assistance Provider #	The provider number the individual was previously assigned by Alaska to use when submitting Medicaid claims.
Are you or have you been previously enrolled as a Medicaid provider in another State?	Select Yes or No to indicate if the individual was previously enrolled as a Medicaid provider in another state other than Alaska.
Other Medicaid State	The other state where the individual was previously enrolled as a Medicaid provider. Select and click the > button to move the choice to the Selected column.
Selected States	The states where the individual was previously enrolled as a Medicaid provider.

Field

Description

Were you previously enrolled in the Alaska Medical Assistance Program?

Select Yes or No to indicate if the individual was previously enrolled as a Medicaid provider in Alaska. If Yes, please enter the AK Medical Assistance Provider #.

Alaska Medical Assistance Provider #

The provider number the individual was previously assigned by Alaska to use when submitting Medicaid claims.

Are you or have you been previously enrolled as a Medicaid provider in another State?

Select Yes or No to indicate if the individual was previously enrolled as a Medicaid provider in another state other than Alaska.

Other Medicaid State

The other state where the individual was previously enrolled as a Medicaid provider. Select and click the > button to move the choice to the Selected column.

Selected States

The states where the individual was previously enrolled as a Medicaid provider.