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, Provider Services Department at (907) 644-6800, option 2, 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.

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
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	12/05/2011
Physician Assistant Provider Addendum	05/26/2009
Physician Provider Addendum	02/10/2010
Provider Enrollment Glossary	08/02/2010
Provider Enrollment Portal (PEP) Overview	08/02/2010
Provider Enrollment Taxonomy Reference	08/02/2010
Provider Type Reference	08/02/2010
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	10/21/2011

Enrollment Documents

Title	Last Modified
Enrollment Instructions for Community Health Aides/Practitioners	10/24/2011
Enrollment Instructions for Dental Health Aides/Therapists	10/24/2011

Existing Providers

Title	Last Modified
Title	Last Modified
Change of Medicaid Provider Information Form	11/08/2011
DHA/T & CHAP Change of Medicaid Provider Information Form	10/26/2011
Dispensing Provider Addendum	02/01/2010
Electronic Remittance (835) Authorization Form	05/06/2010
Enrolled Provider Social Security Number Submission	04/29/2011
NPI Enrollment Requirements	08/13/2009
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
Personal Care Assistant Change of Provider Information Form	06/27/2011
Personal Care Assistant Change of Info Instructions	06/27/2011
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	10/21/2011
Standard Provider Enrollment Form	06/27/2011
Standard Provider Enrollment Form - Attachment A