Alaska Medicaid Provider Revalidation

Welcome to the Alaska Medicaid Provider Revalidation portal. The revalidation application and any required addendums are accessed from this page.
Please note that we cannot accept handwritten revalidation applications; download the form(s) onto your computer for completion. Complete, sign and return the revalidation application and required addendums to:

Conduent State HealthCare
Provider Enrollment
PO Box 240808
Anchorage, AK 99524-0808

For additional information on revalidation, please review the Provider Revalidation FAQs.

For information on the application fee, please review the Provider Application Fee FAQs.

If you would like to submit a new enrollment please visit: Medicaidalaska.com.

If you would like to update an existing enrollment, please complete and submit this form: Update Provider Information Request Form.

If you need revalidation assistance, please contact: AK-Enrollment@Conduent.com.


Group/Facility Revalidation

Group/Facility Revalidation Application

Conduent cannot accept handwritten revalidation applications.


Select the addendum that applies to your provider type. Complete and return the addendum with your revalidation application:


Dispensing Provider Addendum

Home Infusion Addendum

Mental Health Physician Clinic Addendum

Retail Pharmacy Addendum

School-Based Services Addendum

Individual Revalidation

Individual Revalidation Application

Conduent cannot accept handwritten revalidation applications.


Select the addendum that applies to your provider type. Complete and return the addendum with your revalidation application:


Dispensing Provider Addendum

Physician Assistant Addendum

Sole Proprietor Revalidation

Sole Proprietor Revalidation Application

Conduent cannot accept handwritten revalidation applications.


Select the addendum that applies to your provider type. Complete and return the addendum with your revalidation application:


Dispensing Provider Addendum

Mental Health Physician Clinic Addendum

Physician Assistant Addendum

Retail Pharmacy Addendum

Personal Care Assistant Revalidation

Personal Care Assistant Revalidation Application

Conduent cannot accept handwritten revalidation applications.


CHA/P and DHAT Revalidation

CHA/P and DHAT Revalidation Application

Conduent cannot accept handwritten revalidation applications.