Provider Opt In Registration

Organization/Facility Information

List the Organization/Facility name and Facility Provider Identification Number (PIN). Please submit a separate form for each PIN.

* 1. Organization/Facility Name:

* 2. Facility PIN:

* 3. Facility Address

Uninsured Adults Information
List the number of “uninsured adults” seen in the last calendar year (i.e., 01/01/17 through 12/31/17).

“Uninsured adults” are defined as individuals aged 19 years and older who have no third party payer like private insurance, Medicaid, or Medicare. To determine the number of uninsured adults by facility, query your electronic health record (EHR) system for the number of adults aged 19 years and older without a third party payer seen at the medical facility last calendar year.

Providers must pay for a minimum of 50 uninsured adults.  If you serve less than 50 uninsured adults, you will report a total of 50 uninsured adults. For example, if you serve 20 uninsured adults, you will report 50 uninsured adults and be invoiced $528 ($0.88/adult/month x 50 uninsured adults x 12 months).

* 5. Number of uninsured adults

* 6. Who is the individual responsible for paying the bill on your Organization/Facility's uninsured adults:

* 7. Alternative contact information:

Payment and Interest
Payment in full is due on the date of the invoice. Interest will automatically accrue from the invoiced date at 12% annually; however, there will be a 45 day grace period. Any provider may ask that interest be waived, “for good cause shown,” by submitting a written request to the AVAP Council; the matter will be addressed at the next scheduled Council meeting.

Questions
For help determining how to quantify the total number of uninsured adults in your Organization/Facility in the last calendar year, please contact the Immunization Helpline.

 
Anchorage: 907-269-8088
Toll Free: 888-430-4321
Email: immune@alaska.gov

For questions about your invoice, please contact KidsVax ®.

Toll Free: 1-855-543-7329
Email: info@AKvaccine.org

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