Group Provider Enrollment (Demographic) Page

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You use the Demographic page to add or edit group provider's identifying information to the enrollment application.

The Demographic page for Group Provider Enrollment page 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
Group Name	Identifies the full name of the provider group. Note: This field must match the business name provided to the IRS. Payments and tax information are made to this name.
Federal Employer Identification # (FEIN)	Identifies the Federal Employer Identification number of the provider group.
Doing Business As (DBA) Name	Official name under which the provider group is doing business.
Have you ever used a different DBA Name?	Select Yes or No to indicate if your group has ever operated under another business name (Doing Business As name). If Yes, enter the name in the Former DBA Name field.
Former DBA Name	Identifies the former name in which the business was operating under.
Is this application due to a change of ownership?	Select Yes or No to indicate if this application is caused by a change in group ownership. If Yes, enter the previous owner's provider number in the Provider # field.
Provider #	Previous owner's provider number. Required when the answer to change of ownership is Yes.
Requested Enrollment Begin Date	The requested enrollment start date. Enrollment can be requested 12 months retroactively from enrollment submission date.

Field

Description

Group Name

Identifies the full name of the provider group.

Note: This field must match the business name provided to the IRS. Payments and tax information are made to this name.

Federal Employer Identification # (FEIN)

Identifies the Federal Employer Identification number of the provider group.

Doing Business As (DBA) Name

Official name under which the provider group is doing business.

Have you ever used a different DBA Name?

Select Yes or No to indicate if your group has ever operated under another business name (Doing Business As name). If Yes, enter the name in the Former DBA Name field.

Former DBA Name

Identifies the former name in which the business was operating under.

Is this application due to a change of ownership?

Select Yes or No to indicate if this application is caused by a change in group ownership.

If Yes, enter the previous owner's provider number in the Provider # field.

Provider #

Previous owner's provider number. Required when the answer to change of ownership is Yes.

Requested Enrollment Begin Date

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

Previous Medicaid Provider Information Fields

Field	Description
Were you previously enrolled as an Alaska Medicaid Medical Assistance provider?	Select Yes or No to indicate if the group was previously enrolled as a Medicaid provider in Alaska. If Yes, please enter the AK Medical Assistance Provider #.
AK Medical Assistance Provider #	Previous AK Medicaid provider number for the service location you are now applying for. Required when answering Yes to previously being enrolled as a Medicaid provider in AK.
Are you or have you been previously enrolled as a Medicaid provider in another State?	Select Yes or No to indicate if the group was previously enrolled as a Medicaid provider in another state other than Alaska.
Other Medicaid State	The other state where the group 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 group was previously enrolled as a Medicaid provider.

Field

Description

Were you previously enrolled as an Alaska Medicaid Medical Assistance provider?

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

AK Medical Assistance Provider #

Previous AK Medicaid provider number for the service location you are now applying for.

Required when answering Yes to previously being enrolled as a Medicaid provider in AK.

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

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

Other Medicaid State

The other state where the group 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 group was previously enrolled as a Medicaid provider.

Organization Type Field

Field	Description
Type of Organization?	Indicates the type of organization for the group providers. Examples: Partnership, Corporation/LLC,Government/Public

Field

Description

Type of Organization?

Indicates the type of organization for the group providers.

Examples: Partnership, Corporation/LLC,Government/Public

Non-Profit Organization Tax Exempt Status Fields

Field	Description
Is the business listed under tax-exempt status?	Select Yes or No if the group is listed as tax-exempt. If Yes, please send a copy of your IRS-issued exemption. The exemption form is also known as the IRS CP575 Form.

Field

Description

Is the business listed under tax-exempt status?

Select Yes or No if the group is listed as tax-exempt. If Yes, please send a copy of your IRS-issued exemption. The exemption form is also known as the IRS CP575 Form.