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Alaska Medicaid Home Health SA Request Form

Alaska Medicaid uses this two-page request to authorize home health services or to add dates and services to an approved service authorization (SA). It lists the requested revenue and procedure codes, units, charges and dates, together with the diagnosis and medical justification. The home health agency faxes it to the Medicaid fiscal agent, which marks each line authorized or not.

Who completes it

The home health agency completes the provider, member and service lines and signs the item 16 attestation. The ordering practitioner's diagnosis, medical justification and plan of care supply the clinical content for item 10.

Submitting and payment

How to submit it
Fax the completed form directly to the Alaska Medicaid fiscal agent. To change an approved SA, check the update box and enter the existing SA number.
Who pays
Authorization does not guarantee payment: the form states that payment depends on the member's eligibility, so the agency should confirm the member's ID card is current.

Good to know

  • Complete one form per service authorization. Each further update to the same SA needs a new form with the update box checked and the approved SA number entered.
  • The instructions say the dates of service requested in item 9 should match the dates on the plan of care, so the two documents need to line up.
  • Item 10 holds the diagnosis and medical justification for the services; supporting documentation such as the signed plan of care can be attached.
  • Procedure codes must follow Alaska Medicaid's home health billing guidance. The current version is labeled AK-HOME HEALTH SA (07/01/2023).

Get the official form

Download the current version from the source each time; forms change without notice.

Home Health Service Authorization (SA) Request

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who signs the Alaska Medicaid home health SA request?

The professional submitting the request signs item 16 with their title and the date. By signing, they attest that the information is true, accurate and complete, that the services are medically indicated and necessary, and that the content meets Alaska Medicaid program requirements. The ordering practitioner's documentation supports the diagnosis and justification entered in item 10.

How do you update an approved Alaska home health authorization?

Use the same form. Check the box at the top to update an existing SA, enter the approved SA number, and list the additional dates of service or changed services. The form allows one SA per form, so each later update requires a new form with the SA number.