• SHARP Quarterly Report

    AK Department of Health & Social Services
  • Quarterly Work Report

    This report form is to be completed by each SHARP practitioner's respective practice site (agency) representative. The SHARP program must verify that each participant has been delivering healthcare services at the specified practice site during the past quarter. NOTE: This form works best in Google Chrome or Firefox.
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  • Practice information

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  • Sign-Off

    As an authorized site (agency) representative, I certify via my electronic submission that all data contained in this report are accurate and can be substantiated by a record review. • The practitioner named in this report worked as a practitioner during the stated period, at the clinic site(s) listed, and as in accordance with his/her SHARP contract. • This site (agency) used the sliding fee scale or no-pay policy for uninsured patients submitted with the sponsoring site's application. 
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  • Submit

    Click Submit below for this completed form to be sent to the practitioner's email that you included on Page 1 (if necessary, verify the address for accuracy). They will then review, and if they approve then your quarterly report will be complete.
  • Practitioner Sign-Off

    After review of this report for accuracy, please select whether it is approved or denied, and submit.
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