PROVIDER ID: ______________

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Alaska Medical Assistance Program

Alaska Department of Health and Social Services

Dear Provider,

Section 6401(a) of the Affordable Care Act (ACA) established a requirement for all enrolled

providers and suppliers to revalidate their enrollment information under new screening criteria.

In accordance with 42 CFR 455.414, providers enrolled with Alaska Medicaid must revalidate

their enrollment information. Providers who do not complete revalidation within 30 days of

receiving their revalidation letter will have their enrollment deactivated and will not be

eligible to receive Medicaid reimbursement.

Providers who are deactivated and later decide to reactivate their Alaska Medicaid enrollment

are required to complete a new enrollment application through Alaska Medicaid Health

Enterprise.

To revalidate your provider enrollment and continue uninterrupted claims processing, complete

all pages and fields, print, sign, and return this revalidation application to:

Conduent State Healthcare

Provider Enrollment

PO Box 240808

Anchorage, AK 99524-0808

Please answer all fields. Omissions will delay processing and may result in deactivation.

Original signatures are required. Copied or stamped signatures are not acceptable. If you have questions or need assistance, please contact Conduent Provider Enrollment toll-free at 888.944.6877 or in Anchorage at 907.644.5993, or at AK-Enrollment@Conduent.com.

This revalidation will not affect claim submission or payment as long as you complete your revalidation within 30 days upon receipt of your revalidation letter. You may continue to submit claims for reimbursement and receive payment unless you fail to successfully revalidate by the date indicated.

Upon successful revalidation, you will receive a Revalidation Confirmation Email in about 45 days. If you do not receive your Revalidation Confirmation Email please contact Conduent Provider Enrollment at AK-Enrollment@Conduent.com.

For more information about the federal requirements, access The Centers for Medicare & Medicaid Services (CMS) website at: https://www.cms.gov.

Thank you.

SOLE PROPRIETOR PROVIDER REVALIDATION APPLICATION

PROVIDER ID: ______________

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PART 1: INDIVIDUAL INFORMATION

Identifying Information

This name must match the legal name provided to the IRS. Payments and tax forms are issued using this name.

Last Name: First Name: MI:

NPI: Provider ID:

Choose Provider Type:

I do NOT want to continue my enrollment in Alaska Medicaid. Please discontinue my enrollment effective:

I understand that as of this date, I will no longer be eligible for reimbursement of claims by Alaska Medicaid. If selecting this option, please print this form, sign signature pages, and mail original copy to Conduent Provider Enrollment.

PART 2: ADDRESS VERIFICATION

Service Location Address (may not be a P.O. Box). A service location is a practice location where health care services are rendered or managed for services provided to Alaska Medicaid recipients under the Group’s FEIN.

Service Address Line 1:

Service Address Line 2:

City: State: Zip Code: +4:

Mailing Address: The Mailing Address is the postal address for the service location, where provider correspondence will be mailed.

Mailing Address Line 1:

Mailing Address Line 2:

City: State: Zip Code: +4:

Best Contact Person (ALL contact fields below are required)

Last Name: First Name: MI:

Phone #: Ext.: Fax #:

Email Address: Position:

PROVIDER ID: ______________

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Has any person who has ownership of, or a controlling interest in, the provider’s practice or business entity, or who is an agent, managing

employee, contract employee, subcontractor, or employee of the provider’s practice or business entity, ever been convicted of a criminal

offense related to Alaska’s Medical Assistance programs, the Medicaid program in another state or territory, the Medicare program, or any

other federally funded health and social service program? YES NO

Have you or any member of your immediate family ever been convicted, assessed, debarred, or excluded from the Medicaid, Medicare, or

Title XVIII, Title XIX, Title XX Social Security program or any other federal program due to fraud, obstruction of an investigation, or a

controlled substance violation? YES NO

Do you, under any name or business identity, have any outstanding overpayments with any state or federal program? YES NO

Have you ever plead guilty, no content or been sentenced for any felony crime and/or had a criminal fine or restitution order assessed or do

you have a felony charge pending under federal or State law? YES NO

Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever been sanctioned by the

Office of Inspector General (OIG), Medicare, Medicaid, or the Social Security Act, including a state Medicaid program? YES NO

Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever been denied

malpractice insurance or ever voluntarily or involuntarily agreed to any limitations, restrictions, or conditions to your license, certification, or

permit including any formal or informal Professional Board Disciplinary Action(s)? YES NO.

Have you or any of your employees, contract employees, or any person or entity with ownership of your business, ever had any Program

Exclusions from any federally funded program? YES NO

Have you or any of your employees, contract employees, or any person or entity with ownership of your business, been involved in any civil

litigation whereby a judgement or settlement was entered into, or a Civil Monetary Penalty(s) was paid? YES NO

Do you or any of your employees, contract employees, or any person or entity with ownership of your business have any Judgement(s) or

Pending actions under the False Claims Act? YES NO

(If answered yes to any of the above questions, please provide additional information.)

PART 3: EXCLUSIONS and SANCTIONS

PROVIDER ID: _____________

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Alaska Medical Assistance Program

Alaska Department of Health and Social Services

INDIVIDUAL PROVIDER TAX CERTIFICATION AND PROVIDER ENROLLMENT AGREEMENT

****NOTICE**** The purpose of this form is to obtain a provider’s information and agreement to abide by mandated federal and state law and/or regulations, relative to 1) Internal Revenue Service requirements and 2) Medicaid program requirements. A provider may choose to submit IRS Form W-9 as an addendum to this Agreement, however the W-9 may not be provided to the Department in lieu of executing, dating, and providing the original of this form to the Department. Failure to return this dated and fully executed Agreement may exclude a provider from participation in the State of Alaska Medicaid program.

ENROLLMENT INFORMATION

Provider Type:

Provider’s Last Name: First Name: MI: Suffix:

TAX IDENTIFICATION NUMBER CERTIFICATION

Legal Name (as shown on your income tax return)1:

Federal Tax Classification: Individual/Sole Proprietor2 Exempt Payee3

Part I Identification Number I

Enter your social security number (SSN), and Federal Employer Identification Number (FEIN) if applicable, in the box provided. The SSN or FEIN provided must match the name given on the “Legal Name” line above and on Page 1 of this application. Corporations, “S” Corporations, Partnerships, Trusts, Estates, and Limited Liability Companies (“LLC”) may not enroll using this form.

Social Security Number

- -

FEIN

-

Part II Certification

Under penalty of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal

Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS hasnotified me that I am no longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person (defined below).

Certification instructions. You must cross out item 2 above and initial the same if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.

Sign Here

This signature applies only to the certification of the identification number inserted on this form. The Provider Agreement (Part III) must also be signed. Only original signatures are acceptable. Stamped, copied, and otherwise replicated signatures are unacceptable.

Signature of Provider (U.S. Person)4

Date

1Legal Name: The name provided must be your legal name as shown on your income tax return, and must match the enrollment information above. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name.

2Federal Tax Classification: This form is intended for use by individuals and sole proprietors only.

3Exempt Payee Check Box: If you are exempt from backup withholding, check this box. Consult IRS Form W-9 or a tax professional for additional assistance in determining if this applies.

4U.S. Person: For federal tax purposes, you are considered a U.S. person if you are an individual who is a U.S. citizen, or a U.S. resident alien.

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Part III Provider Agreement

I hereby certify that the information provided in my Alaska Medicaid Provider Enrollment Application, Provider Enrollment Agreement, and all required enrollment addenda and attachments is true, accurate, and complete and that I have read this entire form prior to executing the same. With regard to Medicaid and CAMA (Alaska Statutes § 47.07.030 and § 47.08.150, also referred to as “Alaska Medical Assistance” or the “Alaska Medical Assistance Program”) payments made to me for appropriate medically necessary services rendered to eligible claimants, and in accordance with any restriction noted herein, I agree as follows:

1. I am fully responsible for all health care services provided by employees, my subcontractors, contractors, and myself. I certify that thequalifications and credentials of persons providing and billing for health care services through my practice/business are appropriate and inaccordance with Alaska professional licensing, Alaska Medical Assistance program rules, federal and state regulations, statutes, and programrules.

2. I have read 42 U.S.C. 1320a-7 “Exclusion of certain individuals and entities from participation in Medicare and State health care programs” andwill comply with 42 U.S.C. 1320c-5 “Obligations of Health Care Practitioners and Providers of Health Care Services; Sanctions and Penalties;Hearing and Review”, including but not limited to, non-employment of individuals sanctioned by the U.S. Department of Health & HumanServices, Office of Inspector General. I will utilize the U.S. Department of Health & Human Services, Office of Inspector General Exclusion List,located on-line at http://exclusions.oig.hhs.gov to perform the checks required thereunder.

3. I will abide by all Alaska laws, regulations, rules, written polices, and billing manual instructions related to the Alaska Medical AssistanceProgram, including but not limited to, Alaska Statutes (“AS”), Alaska Administrative Code (“AAC”), Title XIX of the Social Security Act, theUnited State Code (“U.S.C.”) and the Code of Federal Regulations (“C.F.R.”) related to the Medicaid and CAMA programs, and the terms ofthis document, including but not limited to, licensure, quality assurance and quality improvement, audit and review, overpayments, timelybilling, and when appropriate to bill third-party resources.

4. I will comply with applicable licensing standards contained in AS Title 08 and AS § 47.32 and regulations adopted thereunder.

5. I will comply with applicable requirements in the Deficit Reduction Act of 2005 (DRA), Pub. L. 109-171, 120 Stat. 4 (2006).

6. I will comply with all federal and state laws, regulations, policies, and rules, including (1) the Health Insurance Portability and Accountability Actof 1996 (HIPAA), Pub. L. No. 104-191, 110 Stat. 1936 (1996), (codified principally at 42 U.S.C. § 1320d-1320d-6), (2) the HIPAA privacy andsecurity regulations; and (3) the HIPAA Title II Administrative Simplification and Compliance Act provisions governing electronic transactionsand code sets, security, unique identifiers and privacy, Pub. L. No. 107-105, 115 Stat. 1003 (2001) codified principally at 45 C.F.R. § 160, §162, and § 164.

7. I will indemnify, save harmless, and defend the State of Alaska, its agents and its employees from any and all claims or actions for injuries or damages sustained by any person or property arising directly or indirectly from my activities under this agreement; however, this provision hasno effect if, but only if, the sole proximate cause of the injury or damage is the state’s negligence.

8. I will provide services or items without discrimination as required by the Civil Rights Act of 1964, 42 U.S.C. § 2000d-2000d-4; and withoutdiscrimination on the basis of handicap as required by Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794, Age Discrimination Act of1975 (42 U.S.C. § 6101, et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. § 794) and the Americans with Disabilities Act of1990 (Pub. L. 101-336, 104 Stat. 327 (1990)).

9. I will comply with disclosure requirements contained at 42 C.F.R. § 455, Subpart B regarding related ownership and control, businesstransactions, and persons convicted of crimes, and provide information related to certain physician referrals under 42 U.S.C. § 1396b(s).

10. I will submit, within 35 days of the date upon a request sent by the U.S. Secretary or the Alaska Medicaid agency, full and complete informationregarding:

a The ownership of, or other financial interest in, any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request (42 C.F.R. § 455.105);

b Any significant business transactions between the provider and any wholly-owned supplier, or between the provider and any subcontractor, during the five-year period ending on the date of request (42 C.F.R. § 455.105).

11. I will repay any overpayment to which I am not entitled, regardless of the origin of the error.

12. I will inform the Alaska Department of Health and Social Services in writing within 30 days of any change in ANY information contained in thisprovider enrollment form.

13. I will not bill or require prepayment by recipients presenting proper identification of eligibility for Medicaid/Denali KidCare/CAMA and agree toaccept as payment in full, the amounts paid in accordance with Alaska statutes, regulations, policy, and program rules. No additional chargewill be billed to the recipient, any member of his or her family, or any other source for supplementation. These provisions do not apply to anyservice or item not covered by Alaska's Medical Assistance program. For other services requiring recipient cost sharing, the provider shallcollect from the recipient the amount of cost sharing in compliance with the state regulations. For long-term care services under Medicaid/Denali KidCare, the recipient may be assigned liability for payment of a portion of the cost of care furnished by the facility.

14. I will bill any and all third-party resources, in accordance with state and federal rules, regulations, policies, and procedures.

15. I will ensure that the fees or charges for services or items furnished to recipients of Alaska's Medical Assistance programs will not exceed thefees or charges for comparable services or items furnished to individuals not covered under Alaska's Medical Assistance programs as providedin state regulations.

16. I will submit billings for services or items furnished within 12 months after the date of service. The 12-month timely filing requirement applies toall claims, including those that must be filed with a third-party carrier. Proof of payment or denial of a third-party claim (Explanation of Benefits)will accompany all billings for recipients with third-party insurance in accordance with state regulations.

17. I will maintain written financial, clinical, and other records as required by state and federal laws and regulations, necessary to demonstrate thenature and extent of the medical necessity, support, care, and services for which payment is requested. I agree to fully disclose any and all

Rev 01/02/2020 6 of 12

records reflecting the extent of services or items furnished to recipients under Alaska's Medical Assistance programs, including any information regarding payments claimed for those services or items. Upon request, records and information will be made available to the Alaska Department of Health and Social Services or its authorized representatives, including the federal grantor agency (US Department of Health and Human Services), the Comptroller General of the United States, the Alaska Medicaid Provider Fraud Control Unit, or any authorized representatives of these agencies.

18. I will comply with review and audit regulations in accordance with state and federal regulation. I will provide the Alaska Department of Healthand Social Services with financial reports, audited or certified cost statements, and substantiated data necessary to establish a basis forreimbursement under Alaska's Medical Assistance program.

19. I will comply with regulations relating to recoupment and recovery of overpayments as provided in state regulation. I will comply withregulations relating to adverse actions as provided in state regulation.

20. I have read and understand the penalties for medical assistance fraud contained at AS 47.05.210.

21. I authorize the Department to verify all information submitted as part of the Alaska Medicaid provider enrollment and enrollment updateprocess.

This Agreement is effective from the date executed until the date the Agreement is terminated by either party. Either party may terminate the Agreement by providing the other party with 30 days advance written notice of intent to terminate. The Alaska Department of Health and Social Services may immediately terminate the Agreement for cause if the individual is excluded from the Medicare and/or the Alaska Medical Assistance or other state Medicaid program(s) for any reason, including suspension or revocation of licensure or certification, becomes ineligible for participation in the Alaska Medical Assistance program, fails to comply with the provisions of this Agreement, or if the provider is or may be placing the health and safety of recipients at risk. The Alaska Department of Health and Social Services may terminate this Agreement without notice if the individual provider has not submitted a claim to the Alaska Medical Assistance Program for 18 months or more.

I attest that I am a citizen or national of the United States, an alien lawfully admitted for permanent residence, or an alien authorized by the U.S. Citizenship and Immigration Services (“USCIS”) to work in the United States.

I certify that I have authority to enter into contracts and agreements as the individual or sole proprietor provider requesting enrollment with the Alaska Medical Assistance Program.

I am a Referring/Ordering/Prescribing only provider. Note: Referring/Ordering/Prescribing only providers are not permitted to submit claims to Alaska Medical Assistance for payment. Check this box if you refer, order or prescribe only for Alaska Medicaid recipients.

Legal Name of Provider Title (Please print or type.)

Signature of Provider Date (Use blue ink. Signature must be for provider named above.)

SUBMISSION INFORMATION

Return this original signed form along with your enrollment fee, if applicable, and any additional required documentation to the address below.

Conduent State Healthcare Attn.: Provider Enrollment P.O. Box 240808 Anchorage, Alaska 99524-0808

If you have questions, please contact Provider Enrollment at 907.644.5993 or 888.944.6877 (toll-free in Alaska).

Alaska Medicaid

Sole Proprietor Provider Disclosure Statement PROVIDER ID: _____________

Rev 01/02/2020 7 of 12

Name of Sole Proprietor: _____________________________________________

All fields must be completed. The following information is required under 42 CFR 455.104 Subpart B - Disclosure of Information by Providers and Fiscal Agents: Information on Ownership and Control. If a field or section does not apply to the disclosing business or practice, annotate an “N/A”. If additional space is needed, attach separate sheets as necessary. Appropriately mark the continued section(s) with the application tracking number or current Alaska Medicaid Provider ID.

Ownership – Corporate Owner

List all corporations with an ownership or control interest of 5 percent or more in the disclosing business or practice. Include the name, corporate tax identification number, primary business address, all Alaska business location addresses, and any P.O. Box addresses.

Legal Name Address Primary Address?

Tax Identification # % Owned

Ownership – Individual Owner

List the name, address, date of birth, and social security number of any individual with an ownership or control interest of 5 percent or more in the disclosing business or practice.

Legal Name Address Date of Birth

(mm/dd/yyyy)

Social Security # % Owned

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

Alaska Medicaid

Sole Proprietor Provider Disclosure Statement PROVIDER ID: _____________

Rev 01/02/2020 8 of 12

Mortgages, Deeds of Trust, Notes

List the creditor name, business address, tax identification number, and value percentage of any mortgage, deed of trust, note, or other obligation secured by the disclosing business or practice if the obligation is 5 percent or more of the value of the business or practice.

Creditor Name Business Address Tax Identification # % of Value

Owner Relationships

List any person with ownership or control interest in the disclosing business or practice that is related to another person with ownership or control interest in the disclosing business or practice as a spouse, parent, child, or sibling.

Owner Name Owner Name Relationship Type

Subcontractor Ownership

List the name and tax identification number of any subcontractor in which the disclosing business or practice has a 5 percent or more interest.

Legal Name Tax Identification # / Social Security #

% Owned

Alaska Medicaid

Sole Proprietor Provider Disclosure Statement PROVIDER ID: _____________

Rev 01/02/2020 9 of 12

Owner/Subcontractor Relationships

List any person with ownership or control interest in any subcontractor in which the disclosing business or practice has a 5 percent or more interest that is related to another person with ownership or control interest in the disclosing business or practice as a spouse, parent, child, or sibling.

Business or Practice Owner Name Subcontractor Owner name Relationship Type

Ownership in Other Disclosing Entities

Does any person with ownership or control interest in the disclosing business or practice listed above have an ownership or control interest in any other Medicaid provider or in any entity that does not participate in Medicaid but is required to disclose ownership and control information due to participation in any of the programs established under Title V Maternal and Child Health Services Block Grant, Title XVIII Social Security Act, or Title XX Social Services Block Grant?

If yes, list the name of the owning person and the name and address of the other disclosing entity.

Other disclosing entities may include a) any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare; b) any Medicare intermediary or carrier; c) any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of health-related services for which it claims payment under any plan or program established under Title V or Title XX of the Act.

Owner Name Other Disclosing Entity Name Other Disclosing Entity Address

Alaska Medicaid

Sole Proprietor Provider Disclosure Statement PROVIDER ID: _____________

Rev 01/02/2020 10 of 12

Managing Employees

List the name, address, date of birth, and social security number of any managing employee in the disclosing business or practice.

Managing employee may be a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.

Legal Name Address Date of Birth

(mm/dd/yyyy)

Social Security #

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

Board of Directors, Officers or Agents

List the name, address, date of birth, and social security number of any person serving as a Board of Director, Officer, or Agent in the disclosing business or practice.

Legal Name Address Date of Birth

(mm/dd/yyyy)

Social Security #

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

___ / ___ / _____

Alaska Medicaid

Sole Proprietor Provider Disclosure Statement PROVIDER ID: _____________

Rev 01/02/2020 11 of 12

Whoever knowingly and willfully makes or causes to be made a false statement or misrepresentation of this statement, may be prosecuted under applicable federal or state laws. Knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of participation in the Alaska Medicaid program.

Original Signature Required

_______________________________________________ _______________________________________________ Name of Authorized Representative Title

_______________________________________________ ________________ Signature of Authorized Representative Date

Complete all sections of the Sole Proprietor Provider Disclosure Statement and return to:

Conduent State Healthcare, LLC Provider Enrollment Unit

PO Box 240808 Anchorage, AK 99524-0808

Department of Health and Social Services

DIVISION OF HEALTH CARE SERVICES Quality Assurance Unit

4501 Business Park Blvd., Bldg L

Anchorage, Alaska 99503-7167

Main: 907.334.2400

Fax: 907.561.1684

Attestation of Provider Application Fee Payment – Sole Proprietor

Complete the following required information, check the applicable box, sign, and return this attestation with the Alaska Medicaid Provider Revalidation Application.

Legal Name of Sole Proprietorship: ______________________________________________________

Provider ID: _______________________________ Tax ID: __________________________________

Contact Name: _____________________________________________________________________

Contact Phone Number: _____________________ Contact Email: ____________________________

Application Fee Payment

Check one box applicable to the sole proprietorship.

Provider is enrolled in Medicare and has paid an application fee to the Medicare contractor.

Date paid: _____________________________

Provider is enrolled in another state’s Medicaid or Children’s Health Insurance Program (CHIP) and has paid an application fee to another state’s Medicaid or CHIP program.

Date paid: _____________________________ State paid: _______________________________

Attach confirmation of application fee payment.

Provider is enrolled as an Alaska Medicaid provider, has more than one location with the same provider type and same tax ID, and has previously paid an application fee for one of those locations.

Date paid: _____________________________

Provider requests an application fee hardship waiver. My hardship, justification, and supporting documentation are attached.

Provider has not paid the application fee to Medicare or another state’s Medicaid or CHIP program.

Enclose a check or cashier’s check for the exact application fee amount $595, payable to State of Alaska.

Whoever knowingly and willfully makes or causes to be made a false statement or misrepresentation of this attestation statement may be prosecuted under applicable federal or state laws. Knowingly and willfully failing to fully and accurate disclose the information requested may result in denial of participation in the Alaska Medicaid program.

Signature Required

_______________________________________ ________________________________ Name of Authorized Representative Title

________________________________ Date

_______________________________________

Signature of Authorized Representative

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