Employer Site Request

Welcome to the

Healthcare Workforce Enhancement Program (HWEP)

Employer Site Request Submission!

Important: Before Submitting Your Request

Take a moment to review the Employer Reference Guide before proceeding. The guide includes essential details about site eligibility and program requirements. Providing accurate and complete information in your submission will help us process it more efficiently.

Before a site request can be submitted, an Employer Affiliation must first be created. Once the Employer Affiliation is established, this form can be used to add employer sites to the program. Please ensure this step is completed to avoid delays in processing your request.

If you have questions during this process, visit HWEP Info or contact program support at oha.wi.info@alaska.gov.

Payer Type Summary

Provide the following data for the previous calendar year for the SITE:

Medicaid and Medicare Billing*

Rows	Total Billed Charges	Total Approved Charges
Medicaid
Medicare

Payer Mix*

Rows	Total Patients	Total Visits	Comments
Indian Health Services
Medicaid
Medicare
Private Insurance
Self-Pay - Full Fee
Self-Pay - No Fee
Self-Pay - Sliding Fee Scale
VA/Tricare
All Others

Signature
By submitting below, I confirm that all information provided is accurate and that the site is committed to fulfilling the obligations required by the HWEP.
Authorized Rep Name*

First NameLast Name
Date*

YearMonthDay
Authorized Rep Email*
example@example.com
Should be Empty: