Forms

New providers meeting the following criteria must enroll using the Provider Enrollment Portal (PEP):

• 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

If you do not meet the criteria above, use the enrollment forms below designated for existing providers only.

Enrollment Forms

Title	Last Modified
Title	Last Modified
Change of Medicaid Provider Information Form	11/08/2011
Change of Provider Information Form - Personal Care Assistant	06/27/2011
Dispensing Provider Addendum	02/01/2010
Electronic Remittance (835) Authorization Form	11/03/2008
Enrolled Provider Social Security Number Submission	04/29/2011
Federally Qualified Health Center Provider Enrollment Form (Existing Providers Only)	02/01/2010
Home Infusion Therapy Provider Addendum	11/03/2008
Information Submission Agreements
Mental Health Physician Clinic Provider Addendum	12/05/2011
Physician Assistant Provider Addendum	05/26/2009
Physician Provider Addendum	02/01/2010
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 (Existing Providers Only)	06/27/2011
Standard Provider Enrollment Form - Attachment A (Existing Providers Only)	12/02/2011

Information Submission Agreement Forms

Title	Last Modified
Billing Agent Information Submission Agreement	07/26/2007
Billing Agent Information Submission Agreement Instructions	08/19/2009
Electronic Remittance (835) Authorization Form	11/03/2008
Provider Information Submission Agreement	08/19/2009
Provider Information Submission Agreement Instructions	08/19/2009

Pharmacy Forms

Title	Last Modified
Botulinum Toxin Prior Authorization Request Form	09/12/2011
General Medication Prior Authorization Request Form	07/01/2011
Synagis Prior Authorization Request Form (fill-in online version)	10/29/2011
More State of Alaska Health Care Services Pharmacy Medication Prior Authorization Forms.

Other Forms

Title	Last Modified
Title	Last Modified
Adjustment/Void Form	11/15/2008
Air Ambulance Flight Summary	10/11/2011
Attachment Fax Cover Sheet	02/01/2009
Care Management Program Provider Statement	10/04/2010
Certificate of Medical Necessity Form	10/28/2011
Certificate of Medical Necessity Form - Incontinence Supplies	10/28/2011
Certificate to Request Federal Medicaid Funds For Abortion	03/31/2011
Check Amount and Claim Status Inquiry Form	11/03/2008
Community Behavioral Health Clinic Service Authorization Request Effective 12/1/11 DOS	12/01/2011
Community Mental Health Clinic Prior Authorization Request Form Effective 1/1/10 DOS (*)	03/12/2010
Community Mental Health Clinic Prior Authorization Form prior to 1/1/10 DOS	12/04/2009
Complaint Form (Suspected Fraud or Abuse)	06/04/2009
Day Treatment Facility Prior Authorization Form	10/15/2009
Handicapping Labiolingual Deviation (HLD) Index Report	12/28/2010
Health Care Forms and Billing Manuals Request Form	05/06/2010
Hysterectomy Consent Form	12/01/2009
Mental Health Physician Clinic Prior Authorization Form Effective 1/1/10 DOS (*)	03/12/2010
Mental Health Physician Clinic Service Authorization Request Effective 12/1/11 DOS	12/01/2011
Mental Health Physician Clinic Prior Authorization Form prior to 1/1/10 DOS	12/04/2009
Pay-To Election Form	08/31/2010
Prior Authorization Request Form	11/03/2008
Provider Appeals Form	11/03/2008
Recipient Eligibility Inquiry Form - General	02/01/2010
Recipient Eligibility Inquiry Form - Vision	02/01/2010
Sterilization Consent Form	07/02/2002
Substance Abuse Prior Authorization Form Effective 1/1/10 DOS (*)	03/12/2010
Substance Abuse Prior Authorization Form prior to 1/1/10 DOS	12/04/2009
Suspected Fraud and Abuse Form	06/04/2009
TPL Avoidance Request Form	11/03/2008
Warrant Status Change Request	06/17/2010