Yes! You can use AI to fill out Medicaid of Alaska Provider Electronic Remittance (835) Authorization and Claims Enrollment Form
Don't type 18 fields by hand. Tell our AI about yourself, or upload a document you already have, and it fills every field in seconds. You check it, then download, print or sign.
The AI does the filling. You just check it.
No typing into boxes, nothing to install.
What this form asks for
The AI fills all of it, from your answers or your documents.
The AI checks your answers before you download
16 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.
Validates that the Provider Name field (ERA_PROV_NAME) contains the full legal name of the institution, corporate entity, practice, or individual provider and is not abbreviated or truncated. Abbreviated names may not match records held by Medicaid of Alaska or EDS, causing enrollment rejection. If this field is left blank or contains an informal name, the enrollment application cannot be processed.
Checks that the Street field contains a valid street number and street name where the provider or organization can be found. A complete street address is required for correspondence and verification purposes during the 4-6 week approval process. Submissions missing a street address or containing only a P.O. Box where a physical address is required will be flagged as incomplete.
Ensures the City field associated with the provider address is completed and does not contain numeric characters, special symbols, or placeholder text. The city must correspond to a real municipality consistent with the provided state and zip code. An invalid or missing city will cause a mismatch during address verification and may delay or reject the enrollment.
Validates that the State/Province field contains exactly a two-character ISO 3166-2 code (e.g., 'AK' for Alaska) and is not spelled out in full or left blank. The payer system requires standardized state codes for proper routing and record matching. Entries with full state names, invalid abbreviations, or numeric values will fail processing.
Checks that the Zip Code/Postal Code field contains either a standard 5-digit ZIP code or a ZIP+4 format (e.g., 99524 or 99524-0808), consistent with the U.S. postal zone improvement plan standard. The zip code must be logically consistent with the city and state provided in the address fields. An incorrectly formatted or mismatched zip code can result in undeliverable correspondence and enrollment failure.
Validates that the Provider Federal Tax Identification Number or Employer Identification Number field is populated and follows the standard 9-digit format (XX-XXXXXXX), as issued by the IRS to identify business entities. This identifier is critical for linking the provider's enrollment to their financial and tax records. A missing, incorrectly formatted, or invalid TIN/EIN will prevent the payer from verifying the provider's identity and processing electronic claims.
And 10 more checks
- National Provider Identifier (NPI) is a Valid 10-Digit Numeric Value
- NPI and TIN/EIN Are Not Identical or Transposed
- Authorized Signature Field is Not Left Blank
- Printed Name of Person Submitting Enrollment is Provided
- Printed Title of Person Submitting Enrollment is Provided
- Submission Date is Present and in a Valid Date Format
- Payer Name Field Matches Expected Value of 'Medicaid of Alaska'
- Provider Medicaid ID Field Does Not Contain Invalid Characters
- All Required Fields Are Populated Before Submission
- Contact Information Fields Do Not Contain Duplicate or Malformed Email/Fax Data
Let AI fill out your Medicaid of Alaska Claims Enrollment
No typing. Every field filled in seconds, checked, ready to sign.
How to Fill Out Medicaid of Alaska Claims Enrollment Online for Free in 2026
What the AI walks you through.
- Navigate to Instafill.ai and upload the Medicaid of Alaska Claims Enrollment Form PDF or select it from the available form library to begin filling it out online.
- Enter the Provider Information, including the complete legal name of the institution, corporate entity, practice, or individual provider in the Provider Name field.
- Fill in the Provider Address details, including street address, city, state/province, zip code/postal code, and country code as required.
- Provide the Provider Identifiers Information, including the Federal Tax Identification Number (TIN) or Employer Identification Number (EIN) and the 10-digit National Provider Identifier (NPI).
- Indicate the reason for submission by selecting New Enrollment, Change Enrollment, or Cancel Enrollment, and specify any Electronic Remittance Advice preferences such as aggregation by TIN or NPI.
- Complete the Authorized Signature section by providing the electronic or printed signature, printed name, and title of the person submitting the enrollment, along with the submission date.
- Review all entered information for accuracy, then mail the original signed form to Conduent HIPAA Provider Support Team at P.O. Box 240808, Anchorage, AK 99524-0808, and email or fax a copy to [email protected] or fax (651) 389-9152, allowing 4-6 weeks for processing.
Common Mistakes in Completing Medicaid of Alaska Claims Enrollment
The ones the AI is built to catch.
Entering an incomplete or incorrect provider legal name
Submitting an incorrect or misformatted TIN/EIN
Entering an invalid or incomplete National Provider Identifier (NPI)
Using an electronic or typed signature instead of an original signature
Mailing a copy instead of the original form
Omitting the provider's title in the authorized signature section
Providing an incomplete or incorrectly formatted provider address
Entering the wrong Payer ID or leaving it blank
Failing to indicate the correct reason for submission
Sending the form to the wrong fax number or email address
Leaving the submission date blank or entering an incorrect date
Confusing individual NPI with group/billing NPI
Frequently Asked Questions About Medicaid of Alaska Claims Enrollment
Is it really free for 7 days?
Can I fill other forms too?
How do I cancel?
How does the AI fill out Medicaid of Alaska Claims Enrollment?
What happens to my information?
How complex is Medicaid of Alaska Claims Enrollment to fill out?
What is the purpose of this form?
Who needs to fill out this form?
What is the Payer ID for Medicaid of Alaska?
What information is required to complete this form?
What is an NPI and where do I find mine?
Where do I submit the completed form?
Is an original signature required on this form?
How long does it take to process this enrollment form?
Who do I contact if I have questions about the enrollment process?
Can I use this form to change or cancel my existing enrollment?
What is the Provider Electronic Remittance (835) Authorization mentioned in the form?
Can I fill out this form online using AI tools?
What if the PDF form is not fillable?
What does 'Payer Values on Billing/Group NPI' mean on this form?
Do I need to submit both an original and a copy of the form?
Get your Medicaid of Alaska Claims Enrollment filled out by AI
$0 today. Cancel before Nov 11 and you pay nothing.
Other forms like this one
Medicaid forms: Alabama Medicaid Agency ABA Therapy Assessment Form (6/20/19) — Behavior Assessment and Treatment Request (CPT 97151) for Applied Behavioral Analysis for Autism Spectrum Disorder, Medicaid Managed Care Applied Behavior Analysis — Authorization Request (Healthy Blue Louisiana, BLAPEC-1989-20), Arkansas Medicaid Applied Behavioral Analysis (ABA) Authorization Request, Agreement of Financial Responsibility - Medicaid, Utah Department of Health Provider Agreement for Medicaid, Utah Medicaid Doula Provider Attestation, 42 CFR Part 489 - Provider Agreements and Supplier Approval (Centers for Medicare & Medicaid Services), Medicaid Alaska EDI Enrollment - Provider Information Submission Agreement, Arkansas Medicaid Provider Application Packet (DMS-652), Form HFS 3082, Drug Prior Authorization Request Form, Medicaid of Minnesota (Administered by HealthPartners of Minnesota) EDI Trading Partner Enrollment Form, New York State Medicaid Enrollment Form (EMEDNY-436701), New York State Medicaid Enrollment Form, Provider Enrollment Agreement (OHA 3975), Oregon Medicaid ID Application Form, Autism Spectrum Disorder Diagnostic Checklist for Medicaid Participants, Form CMS-1539, Long-Term Care Facility Application for Medicare and Medicaid, Medicaid Clinical Trial Attestation Form, West Virginia Medicaid Hepatitis-C Therapy Prior Authorization Form
VA claim forms: Form OWCP-915, Claim for Medical Reimbursement, Form 8862, Information To Claim Certain Credits, Form CA-7, Claim for Compensation, Form CA-5, Claim for Compensation, Form SC-100, Plaintiff's Claim and ORDER to Go to Small Claims Court, Form 20-0995, Decision Review Request: Supplemental Claim, Form 104, List of Creditors 20 Largest Unsecured Claims, Form 941-X (Rev. April 2023), Adjusted Employer’s QUARTERLY Federal Tax Return or Claim for Refund, Judicial Council of California Form SC-104, Proof of Service (Small Claims), Immigration and Refugee Board of Canada (IRB) – Refugee Protection Division (RPD) Basis of Claim Form (for persons claiming refugee protection in Canada) (RPD.02.01), SC-108, Request to Correct or Cancel Judgment and Answer (Small Claims), Judicial Council of California Form SC-105, Request for Court Order and Answer (Small Claims), SC-120, Defendant’s Claim and ORDER to Go to Small Claims Court (Small Claims), Judicial Council of California Form SC-104, Proof of Service (Small Claims), Continental American Insurance Company (CAIC) / Aflac Group Critical Illness Claim Form (with Attending Physician’s Statement, HIPAA Authorization to Obtain Information, and Electronic Funds Transaction Authorization), Judicial Council of California Form SC-108, Request to Correct or Cancel Judgment and Answer (Small Claims), SC-105, Request for Court Order and Answer (Small Claims), Judicial Council of California Form SC-120, Defendant’s Claim and ORDER to Go to Small Claims Court (Small Claims), Small Claim and Notice of Small Claim (ORS 46.425) (OJD Official) (Jan 2026), VA Form 21-4138, Statement in Support of Claim
authorization forms: Form I-765, Application for Employment Authorization, Form CMS-588, EFT Authorization Agreement, Form 8821, Tax Information Authorization, Form 8879, IRS e-file Signature Authorization, Form SSA-827, Authorization to Disclose Information, Form I-905, Application for Authorization to Issue Certification for Health Care Workers, Form G-1650, Authorization for ACH Transactions, Arizona Form 285, General Disclosure/Representation Authorization Form, Arizona Form 285-I, Individual Income Tax Disclosure/Representation Authorization Form, The Department of Medical Assistance Services Applied Behavior Analysis Preservice Service Authorization Request Form (Effective Dates of Service 09/01/2025 and after), Form CH-006: PA-BH-Res-PCS, Oregon Behavioral Health Support Program Plan of Care Authorization (Plan of Care Request for Behavioral Health Residential or Personal Care Services), Continental American Insurance Company (CAIC) / Aflac Group Critical Illness Claim Form (with Attending Physician’s Statement, HIPAA Authorization to Obtain Information, and Electronic Funds Transaction Authorization), HIPAA Authorization Form, Authorization for the Release of Protected Health Information, Form G-1450, Authorization for Credit Card Transactions, Prior Authorization (PA) Request Form – Adult Palliative Care (Alameda Alliance for Health), Alameda Alliance for Health Prior Authorization (PA) Request Form – Adult Palliative Care, Manulife Group Benefits Drug Prior Authorization Form – Mounjaro (Tirzepatide) (GL5197E), Manulife Group Benefits Drug Prior Authorization Form (Ozempic/Semaglutide) – GL5197E, Out-of-Network Pre-Authorization and Exception Request Form, Form SSA-827 (06-2024), Authorization to Disclose Information to the Social Security Administration (SSA)
Medicaid authorization forms: Medicaid Managed Care Applied Behavior Analysis — Authorization Request (Healthy Blue Louisiana, BLAPEC-1989-20), Arkansas Medicaid Applied Behavioral Analysis (ABA) Authorization Request, West Virginia Medicaid Hepatitis-C Therapy Prior Authorization Form
enrollment forms: Form CMS-855O, Medicare Enrollment Application, Form CMS-4040, Request for Enrollment in Medicare Part B, Form CMS-40B, Application for Enrollment in Medicare Part B, Providence Health Plan Out-of-Area Dependent Enrollment Form, Empower Enrollment Form, Empower Enrollment Form, Principal Life Insurance Company UCTIE INTERNATIONAL UNION 401(K) SAVINGS PLAN Enrollment Form, Enrollment Application, Northwell Residents Open Enrollment Benefits Guide 2026, University of Colorado 403(b) Plan – DSW Scudder Enrollment and Beneficiary Designation Form, Merrill Funds Transfer Service Enrollment Form, Funds Transfer Service Enrollment Form, Standing Letter of Authorization / Instruction Enrollment Form, Merrill RMD Service Enrollment and Authorization Form, Fidelity Investments Account Application/Enrollment Form and Beneficiary Designation, MyMerrill® Client Order Entry Enrollment Form, CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners, Form CMS-855R, Medicare Enrollment Application - Reassignment of Medicare Benefits, CMS-855R, Medicare Enrollment Application: Reassignment of Medicare Benefits, CMS-855R, Medicare Enrollment Application: Reassignment of Medicare Benefits
provider enrollment forms: CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement Checklist, CMS-855A, Medicare Enrollment Application for Institutional Providers, Form CMS-855A, Medicare Enrollment Application for Institutional Providers, Medicaid Alaska EDI Enrollment - Provider Information Submission Agreement, Arkansas Medicaid Provider Application Packet (DMS-652), Form HFS 2243, Provider Enrollment Application Illinois Medical Assistance Program, Form CMS-855R, Medicare Enrollment Application - Reassignment of Medicare Benefits, Provider Enrollment Agreement (OHA 3975), Oregon Medicaid ID Application Form, Provider Group/Facility Application (RA-02), Indiana Health Coverage Programs (IHCP) Managed Care Entity (MCE) Provider Enrollment Form
Alaska Medicaid forms: Medicaid Alaska EDI Enrollment - Provider Information Submission Agreement
EDI enrollment forms: Medicaid Alaska EDI Enrollment - Provider Information Submission Agreement, Form CMS-855O, Medicare Enrollment Application, Form CMS-4040, Request for Enrollment in Medicare Part B, Form CMS-40B, Application for Enrollment in Medicare Part B, CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners, Form CMS-855R, Medicare Enrollment Application - Reassignment of Medicare Benefits, CMS-855R, Medicare Enrollment Application: Reassignment of Medicare Benefits, CMS-855R, Medicare Enrollment Application: Reassignment of Medicare Benefits, Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers, CMS-855S, CMS-855B, Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers, CMS-855A, Medicare Enrollment Application for Institutional Providers, Form CMS-855A, Medicare Enrollment Application for Institutional Providers, Medicare Enrollment Application - Medicare Diabetes Prevention Program (MDPP) Suppliers, Form CMS-20134, Form HFS 2243, Provider Enrollment Application Illinois Medical Assistance Program, Medicaid of Minnesota (Administered by HealthPartners of Minnesota) EDI Trading Partner Enrollment Form, Medical Baseline Allowance Application (Used for Medical Baseline Enrollment and Re-Certification), Form CMS-40B, Request for Enrollment in Medicare Part B (Medical Insurance), Form CMS-40B, Application for Enrollment in Medicare Part B (Medical Insurance) (01/24), Form CMS-18-F-5, Application for Medicare Part A (Hospital Insurance)
Let AI fill out your Medicaid of Alaska Claims Enrollment
Your trial starts once a card is added. You pay nothing before Nov 11.
Our AI already knows this form, all 18 fields of it. Skip the typing: tell it about yourself, or upload what you have, and it fills the whole form in seconds.
- AI fills every field on all 3 pages, checkboxes included
- No typing into boxes: answer a few questions, or upload a document you already have, an old copy of this form, a photo of a document
- The AI checks the answers; you review and change anything before you download
- Download the finished PDF, print it, or sign it online
- Encrypted, and never used to train AI
Cancel before Nov 11 and you pay nothing.
A card is needed to start the trial. Cancel in two clicks from your account.
Terms · Privacy