Page 2 of 3
Revised 10/09/13
Section I. Terms of Agreement, continued (To be completed by the “Provider”)
11. I agree that I will not submit claims that may be payable by another resource, unless specifically waived by
federal or state rules, or for claims that have already been paid.
12. I agree to comply with state and federal records retention laws that govern records maintained by my Billing
Agent or me and to provide access to my records and the records maintained on my behalf by my Billing Agent
for reviews and audits as required by state and federal laws.
13. I agree to protect my assigned State identification numbers (including submitter numbers) and State passwords
against unauthorized use.
14. I agree that any changes in my business ownership and/or with my Billing Agent will not change my
responsibility or liabil
ity under this agreement, until such time as I make written notification to the State or its
designee of any such change.
15. (a) I agree to notify the State, by the close of business on the next working day for the State of Alaska, if for
any reason I revoke or terminate any agreement with the above Billing Agent.
(b) I agree to notify the State of any change to my or my Billing Agent’s address, telephone, or other required
information within 3 working days.
(c) I agree to execute a new Department of Health and Social Services Information Submission Agreement
prior to allowing any Billing Agent to submit information to the State on my behalf.
16. Billing Agent Information: I authorize the following Billing Agent to submit information, including claims, on
my behalf (Complete this item ONLY if
you will be billing indirectly through a Billing Agent, Clearinghouse,
contractor, or other entity):
___________________________ ________________________________ ____________________________
Billing Agent’s Business Name Billing Agent’s Telephone Number Billing Agent’s Fax Number
___________________________
________________________________ ____________________________
Billing Agent’s Mailing Address City State
Zip + 4
___________________________
________________________________ ____________________________
Billing Agent’s Physical Address City State
Zip + 4
___________________________
____________________________ ___________________________________
Billing Agent’s Contact Name Contact’s Telephone Number Contact’s Email Address (if applicable)
17. I understand and agree to comply with all items numbered 1-16 listed above. By my signature below, I
acknowledge my responsibility for compliance with this agreement and my authority to enter into this
agreement on behalf of the Provider. Additionally, by my signature below, I, the Provider, authorize the
Billing Agent named above to submit information, including claims, on my behalf. No photocopies or
facsimile signatures will be accepted.
_____________________________________________________ _____________________________________________
Provider Business Name (print) State Provider Identification Number
(Only one ID per Agreement see instructions)
______________________________________________
_________________________________________
Provider’s Name* or Authorized Representative’s Name**
Title as applicable (print)
______________________________________________
_________________________________________
Signature of Provider* or Authorized Representative**
Date of Signature
*Individuals and sole proprietors must sign their own enrollment agreement form.
**An authorized representative is the duly appointed official of any business organized under the laws of the state of
Alaska or other state, to operate as a corporation, partnership, LLC, joint venture, or similar organization ("entity"),
who has the legal authority to enroll the entity in the Alaska Medical Assistance program, to make changes and/or
updates to the enrollment status of the entity, and to commit the entity to the terms and conditions set forth in this
enrollment application. The authorized representative must be a general partner, chairman of the board, chief
financial officer, chief executive officer, president, or direct owner of at least 5% or more of the entity seeking
enrollment, or must hold a position of similar status.
Office Ally Submitter ID AK03373
1300 SE Cardinal Court STE 190
