Enrollment Applications
Before submitting claims to the Alaska Medical Assistance Program, you must first enroll as a Medical Assistance Provider using the Provider Enrollment Portal (PEP). This includes:
- 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
Additions or changes to existing provider records can be done by downloading the appropriate form.
A general overview of PEP can be found here.
Click here to begin processing a new enrollment. Online training is available to provide additional guidance. Enrollment information may also be obtained by calling Affiliated Computer Services, Inc., Provider Services Department at (907) 644-6800 within Anchorage or outside of Alaska and (800) 770-5650 from other Alaska locations. Application forms may also be obtained by downloading the appropriate form from the list presented here.

You will need Adobe® Reader to view any printable PDF document(s).
Click the button above to download a free copy of Adobe® Reader.
Please print and complete the appropriate enrollment form and mail to:
Provider Enrollment
P.O. Box 240808
Anchorage, Alaska 99524-0808
New Providers
| Title | Last Modified |
|---|---|
| Title | Last Modified |
| Provider Enrollment Portal (PEP) Overview | 08/02/2010 |
| Provider Type Reference | 08/02/2010 |
| Provider Enrollment Taxonomy Reference | 08/02/2010 |
| Provider Enrollment Glossary | 08/02/2010 |
| Dispensing Provider Addendum | 02/01/2010 |
| Electronic Remittance (835) Authorization Form | 05/06/2008 |
| Home Infusion Therapy Provider Addendum | 07/07/2010 |
| Information Submission Agreements | |
| Mental Health Physician Clinic Provider Addendum | 02/01/2010 |
| Physician Assistant Provider Addendum | 05/26/2009 |
| Physician Provider Addendum | 02/10/2010 |
| Residential Psychiatric Treatment Center Provider Addendum | 02/01/2010 |
| Residential Psychiatric Treatment Center Provider Letter of Attestation | 05/26/2009 |
| Retail Pharmacy Provider Addendum | 02/01/2010 |
| School Based Service Provider Addendum | 02/01/2010 |
Existing Providers
| Title | Last Modified |
|---|---|
| Title | Last Modified |
| Enrollment Requirements | 08/13/2009 |
| Standard Provider Enrollment Form | 02/01/2010 |
| Standard Provider Enrollment Form - Attachment A | 02/01/2010 |
| Change of Medicaid Provider Information Form | 03/03/2009 |
| Dispensing Provider Addendum | 02/01/2010 |
| Electronic Remittance (835) Authorization Form | 05/06/2010 |
| Federally Qualified Health Center Provider Enrollment Form | 02/01/2010 |
| Home Infusion Therapy Provider Addendum | 07/07/2010 |
| Information Submission Agreements | |
| Mental Health Physician Clinic Provider Addendum | 02/01/2010 |
| Physician Assistant Provider Addendum | 05/26/2009 |
| Physician Provider Addendum | 02/10/2010 |
| Residential Psychiatric Treatment Center Provider Addendum | 02/01/2010 |
| Residential Psychiatric Treatment Center Provider Letter of Attestation | 05/26/2009 |
| Retail Pharmacy Provider Addendum | 02/01/2010 |
| School Based Service Provider Addendum | 02/01/2010 |
