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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.
See the Enrollment page.
Information Submission Agreement Forms
|Billing Agent Information Submission Agreement||07/26/2007|
|Billing Agent Information Submission Agreement Instructions||08/19/2009|
|Electronic Remittance (835) Authorization Form||02/03/2012|
|Provider Information Submission Agreement||08/19/2009|
|Provider Information Submission Agreement Instructions||08/19/2009|
|Botulinum Toxin Prior Authorization Request Form||05/14/2012|
|General Medication Prior Authorization Request Form||07/01/2011|
|More State of Alaska Health Care Services Pharmacy Medication Prior Authorization Forms.|
Service Authorization Forms
|Air Ambulance Flight Summary||02/28/2012|
|Attachment Fax Cover Sheet||03/02/2012|
|Care Management Program Provider Statement||03/02/2012|
|Check Amount and Claim Status Inquiry Form||03/02/2012|
|Complaint Form (Suspected Fraud or Abuse)||03/02/2012|
|Handicapping Labiolingual Deviation (HLD) Index Report||03/02/2012|
|Health Care Forms and Billing Manuals Request Form||03/27/2012|
|Pay-To Election Form||03/02/2012|
|Provider Appeals Form||03/02/2012|
|Recipient Eligibility Inquiry Form - General||03/02/2012|
|Recipient Eligibility Inquiry Form - Vision||03/02/2012|
|Suspected Fraud and Abuse Form||03/02/2012|
|TPL Avoidance Request Form||11/03/2008|
|Warrant Status Change Request||03/02/2012|