Forms

 

Enrollment Forms

Title
Provider Enrollment Forms

Pharmacy Forms

Title
Pharmacy Forms
More State of Alaska Health Care Services Pharmacy Medication Prior Authorization Forms.

Service Authorization Forms

Title Last Modified
Title Last Modified
Autism Service Authorization Request Form 09/24/2018
Certificate of Medical Necessity Form 01/03/2017
Certificate of Medical Necessity Form - Incontinence Supplies 10/03/2019
Certificate to Request Funds for Abortion 11/01/2012
Community Behavioral Health Clinic Service Authorization Request Up to Twelve Hours
(for dates of service through 12/31/2018)
02/22/2017
Community Behavioral Health Clinic Service Authorization Request Up to Twelve Hours
(for dates of service on and after 01/01/2019
02/12/2019
Community Behavioral Health Clinic Service Authorization Request Greater Than Twelve Hours
(for dates of service through 12/31/2018)
12/11/2018
Community Behavioral Health Clinic Service Authorization Request Greater Than Twelve Hours
(for dates of service on and after 01/01/2019
02/12/2019
Consent for Sterilization Form 04/30/2019
Dental Service Authorization Request Form 12/15/2017
Dental Service Authorization Update Request Form 04/04/2017
Genetic Testing Supporting Information 01/03/2017
Handicapping Labiolingual Deviation (HLD) Index Report 01/03/2017
Hysterectomy Certification and Consent Form 02/15/2019
Local Travel Service Authorization Request 09/11/2019
Mental Health Physician Clinic Service Authorization Request (for dates of service through 12/31/2018) 01/03/2017
Mental Health Physician Clinic Service Authorization Request (for dates of service on and after 01/01/2019 02/12/2019
Orthodontic Referral - Oral Health and Hygiene Assessment 03/31/2016
Out-of-Area Travel Service Authorization Request 09/11/2019
Prior Authorization Request Form (See Service Authorization Request Form )
Service Authorization Request Form 04/27/2018
Transportation Authorization Update Form 01/03/2017
Vision Service Authorization Request Form 09/01/2019

Other Forms

Title Last Modified
Title Last Modified
Adjustment/Void Form 01/03/2017
Air Ambulance Flight Summary 01/03/2017
Attachment Fax Cover Sheet 01/03/2017
Care Management Program Provider Statement 01/03/2017
Check Amount and Claim Status Inquiry Form 01/03/2017
Complaint Form (See Suspected Fraud and Abuse Form)
DME Alternate Reimbursement Rate Request 07/02/2019
DME/POS Price Research Request 06/02/2019
Electronic Remittance (835) Authorization Form 01/03/2017
Eligibility Verification Form (See Recipient Eligibility Verification Forms)
Genetic Testing Supporting Information 01/03/2017
Handicapping Labiolingual Deviation (HLD) Index Report 01/03/2017
Healthcare Forms Order Request 04/05/2019
Member Appointment No-Show Report 04/15/2019
Organization Administrator Change Request Form 01/03/2017
Orthodontic Referral - Oral Health and Hygiene Assessment 03/31/2016
Pay-To Election Form 01/03/2017
Provider First-Level Appeal Request Form 01/03/2017
Recipient Eligibility Inquiry Form - Dental 06/30/2017
Recipient Eligibility Inquiry Form - General 02/10/2017
Recipient Eligibility Inquiry Form - Vision 02/10/2017
Remittance Advice Sort Request 01/03/2017
Suspected Fraud and Abuse Form 01/03/2017
TPL Avoidance Request Form 01/03/2017
Travel Voucher Request Log 10/04/2019
Warrant Status Change Request 01/03/2017