Alaska Medicaid providers use this form to request service authorization, the program's prior authorization, for medical services other than dental, long-term care and behavioral health. The requesting provider supplies facility and member details, the primary diagnosis code, dates of service, medical justification and the procedure codes, modifiers, units and charges requested, then signs an attestation of medical necessity.
The requesting provider completes items 1 through 20, and the signature must be that of the professional attesting that the content is accurate and meets Alaska Medicaid program requirements. Items 21 to 29 are reserved for the Alaska Medicaid Fiscal Agent.
Download the current version from the source each time; forms change without notice.
Service Authorization Request
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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Medical services requiring authorization other than dental, long-term care and behavioral health, which use separate processes. Some services have their own forms, such as vision, private-duty nursing and the physician-administered drug general prior authorization form.
The professional who, by signing, attests that the completed form is accurate and meets Alaska Medicaid program requirements and that the requested services are medically indicated and necessary. The signature line also asks for the signer's title and the date.