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Provider Type
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Identifying Information- Section 1
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Select Date
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Note: Your SSN / ITIN will be linked to your Alaska Medical Assistance Provider number. All claims paid to your Alaska Medical Assistance Provider number will be submitted as income under your SSN / ITIN to the IRS. If you plan to bill using your Employer Identification Number (FEIN), the group through whom you plan to bill must complete a separate application and list you as an affiliated member, which links you to their FEIN.
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Previous Medicaid Provider Information
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*Are you or have you been previously enrolled as a Medicaid provider in another State?

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