Provider Enrollment Forms

 

For information on submitting documents needed to support your enrollment applications, consult the Provider Enrollment Document Submission Job Aid

Individual

Group/Facility

Title Last Modified
Title Last Modified
Individual Provider Agreement and Tax Certification 05/01/2018
Attestation of Provider Enrollment Fee Payment - Sole Proprietor 12/13/2021
Provider Application Fee FAQs 12/13/2021
Behavior Analyst Addendum 05/21/2018
Dispensing Provider Addendum 01/03/2017
Mental Health Physician Clinic Addendum 11/19/2020
Physician Assistant Addendum 01/03/2017
Provider Disclosure Statement - Sole Proprietor 01/03/2017
Provider Information Submission Agreement (PISA) 10/09/2013
Provider Request to Cancel Alaska Medicaid Enrollment 01/03/2017
Registered Pharmacist Addendum 07/01/2020
Request to Backdate Provider Enrollment Form 08/16/2022
Request to Cancel Alaska Medicaid Provider Application 06/16/2022
Retail Pharmacy Addendum 01/03/2017
Update Electronic Funds Transfer (EFT) Form 01/03/2017
Update Provider Information Request Form 01/03/2017
Title Last Modified
Title Last Modified
Transportation Attestation Form: Individual 12/15/2021
Transportation Attestation Form: Group 12/15/2021
Group/Facility Provider Agreement and Tax Certification 06/05/2019
Attestation of Provider Enrollment Fee Payment - Group 12/13/2021
Provider Application Fee FAQs 12/13/2021
Behavior Analyst Addendum 05/21/2018
Care Coordination Agreement (Transfer and Referral Agreement) 07/08/2022
Dispensing Provider Addendum 01/03/2017
Home Infusion Addendum 01/03/2017
Mental Health Physician Clinic Addendum 11/19/2020
Pharmacy Professional Group Addendum 07/01/2020
Provider Disclosure Statement - Group 01/03/2017
Provider Information Submission Agreement (PISA) 10/09/2013
Provider Request to Cancel Alaska Medicaid Enrollment 01/03/2017
Request to Backdate Provider Enrollment Form 08/16/2022
Request to Cancel Alaska Medicaid Provider Application 06/16/2022
Residential Psychiatric Treatment Center Provider Addendum 01/03/2017
Residential Psychiatric Treatment Center Provider Letter of Attestation 06/01/2014
Retail Pharmacy Addendum 01/03/2017
School-Based Services Addendum 01/03/2017
Update Electronic Funds Transfer (EFT) Form 01/03/2017
Update Provider Information Request Form 01/03/2017

CHA/P, DHAT, BHA

PCA

Title Last Modified
Title Last Modified
CHA/P, DHAT, BHA Provider Enrollment Agreement 01/25/2018
Update Provider Information Request Form 01/03/2017
Title Last Modified
Title Last Modified
PCA Provider Enrollment Agreement 01/03/2017
Update Provider Information Request Form 01/03/2017

Trading Partner

Title Last Modified
Title Last Modified
Billing Agent Information Submission Agreement (BAISA) 10/09/2013