Employer Affiliation Request

Employer Affiliation Request

Healthcare Workforce Enhancement Program (HWEP)
Employer Information
Organization Name
Organization Address

Street Address

Street Address Line 2

CityState

Zip Code
Organization Type: (select one)
How many clinics, sites, and/or locations are managed by the organization?
Contacts
Authorized Representative

First NameLast Name
Auth Rep - Title
Auth Rep - Email
example@example.com
Auth Rep - Phone Number
Please enter a valid phone number.Format: 000-000-0000.
Report Contact

First NameLast Name
Report Contact - Title
Report Contact - Email
example@example.com
Report Contact - Phone Number
Please enter a valid phone number.Format: 000-000-0000.
Finance Contact

First NameLast Name
Finance Contact - Title
Finance Contact - Email
example@example.com
Finance Contact - Phone Number
Please enter a valid phone number.Format: 000-000-0000.

Commitments
Does your organization acknowledge and commit to submitting quarterly reports, as required under 7 AAC 24.071, detailing provider service hours, work locations, and types of services provided (excluding Protected Health Information), within 30 days of the end of each quarter?
Does your organization acknowledge and agree to meet the quarterly payment requirements outlined in AS 18.29.110, including administrative and provider payments?
Attachments
Credential Verification Process

Attach a copy of the process used for certification verification (e.g, licensure checks, National Practitioner Data Bank verification) as required under 7 AAC 24.021
Cancelof
Recruitment and Retention Plan

Attach a copy of your recruitment and retention plan.
Cancelof

Payer Type Summary

Provide the folowing date for the previous calendar year for the EMPLOYER

Medicaid and Medicare Billing

Payer Mix

Employer Site Information
In addition to this Employer Affiliation Request, each facility or clinic where participating providers will be employed must submit an Employer Site Request. This addendum includes site-specific details. A site is approved only after submission and Department of Health approval.

Signature
By signing below, I confirm that all information provided is accurate and that the employer is committed to fulfilling the obligations required by the HWEP.
Authorized Representative Name

First NameLast Name
Date

YearMonthDay
Should be Empty:

Employer Information