Clone of 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)*

Governmental Entity - LocalGovernmental Entity - StateFor-Profit HealthcareNon-Profit HealthcareTribal Health Organization
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.
Report Contact*

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

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

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?*

YesNo
Does your organization acknowledge and agree to meet the quarterly payment requirements outlined in AS 18.29.110, including administrative and provider payments?*

YesNo
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*

	Total Billed Charges	Total Approved Charges
Medicaid
Medicare

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 Affiliation Request