SHARP Employer App. Part 1 - Organization Info

SHARP Employer Application Part 1 - Organization Information

AK Department of Health & Social Services
- Please enter information about the health care system or organization that owns or otherwise operates the practice site described in this application
- Administrator identified in the section must be person who will sign certification statement, as well as future SHARP contracts
Name of Employer *
Type of Employer *

Public (Gov't) Private Non-Profit Private For-Profit
Federal Tax ID *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer Administrator *

First Name Last Name
Title *
Phone Number *

Area Code Phone Number
Email *
example@example.com

Provide a 12 month billing summary

Medicaid

Medicare

Self-Pay: Sliding Fee Scale

Self-Pay: Full Fee Scale

No Charge or Payment

Private Insurance

I.H.S Payment

Total

For your agency's overall patient population, what percentage do each of the following groups compose? (these may not add to 100%)

Percentage

Uninsured

Medicaid recipients

Medicare recipients

Alaska Native/American Indian

Recipients of other federal healthcare benefits
(except for federal employer health benefits)

Employer Payments

An employer approved for participation in the program shall make a nonrefundable quarterly payment to the department for the purpose of partial resourcing of the practitioner's SHARP service contract. That payment amount is specified within each contract.
Partial Waiver of Required Employer Payment

Note: If marked "yes," employer is asserting, and is providing documentation, that:

1) At least 50% of patients are considered "underserved" OR at least 50% of revenue comes from patients who are considered "underserved" and

2) Entity has "inability to pay" the required employer payment and is providing evidence of that inability, and

3) Entity recognizes that DHSS Commissioner must sign authorization for partial waiver of required employer match

If marked yes, site must file a match waiver request form and other supplemental attachments
Does the Employer plan to apply for a partial waiver of required employer payment? *

Yes No
In the event that the employer has more than one practitioner that has applied for SHARP during this solicitation cycle, the employer accepts that it may be asked to prioritize and/or limit the number of practitioner-applicants that it will endorse for participation in SHARP. *

Yes No

SHARP - Employer Application Attestation Page

Authorized Employer Representative (CEO or Site-Authorized Administrator)
1. As an employer representative, I certify via my signature here that all data contained in any SHARP Employer Application are accurate and can be substantiated by a record review.

2. I recognize and accept that if (any) practitioner(s) who are working for our agency (Site) are admitted to this SHARP program, then there will be a required employer match, to be invoiced on a quarterly basis. I understand that the payment details of this employer match will be specified in the required Memorandum of Agreement service contract. The MOA is presented for final consideration to both the Employer and Practitioner for potential signatures before service-credit begins.

3. I recognize and accept that if the Employer is found eligible for participation in the SHARP opportunity, then the State of Alaska may request further data and attestation following eligibility determination.
Authorized Employer Representative's Name *

First Name Last Name
Authorized Employer Signature *

Clear
Employer Organization *
Representative's email *
example@example.com
Representative's phone number *

Area Code Phone Number
Acknowledgement: I recognize that Part 2 of the SHARP Employer Application must be subsequently completed for each practitioner position for which my organization is applying. *

Yes No
Should be Empty:

SHARP Employer Application Part 1 - Organization Information