Alaska Affidavit & Memorandum, SHC-1301

• Category: Alaska Statewide - Fairbanks - Small Claims
• State: Alaska
• Control #: AK-SHC-1301
• Format: PDF

Description

Affidavit & Memorandum, SHC-1301 Alaska Affidavit & Memorandum, SHC-1301 is a form issued by the Alaska Department of Health and Social Services (DSS). It is used to document the health care services provided to a patient under the Alaska Medical Assistance Program. The form includes a patient's name, date of birth, Medicaid number, and the name of the provider who provided the services. The form is typically signed by both the provider and the patient. There are two types of Alaska Affidavit & Memorandum, SHC-1301: 1. Medicaid Reimbursement Affidavit & Memorandum, SHC-1301: This form is used by a provider to submit a claim to Medicaid for reimbursement of services provided to a patient. 2. Non-Reimbursement Affidavit & Memorandum, SHC-1301: This form is used to document services provided to a patient that are not eligible for reimbursement under the Alaska Medical Assistance Program.

Alaska Affidavit & Memorandum, SHC-1301 is a form issued by the Alaska Department of Health and Social Services (DSS). It is used to document the health care services provided to a patient under the Alaska Medical Assistance Program. The form includes a patient's name, date of birth, Medicaid number, and the name of the provider who provided the services. The form is typically signed by both the provider and the patient. There are two types of Alaska Affidavit & Memorandum, SHC-1301: 1. Medicaid Reimbursement Affidavit & Memorandum, SHC-1301: This form is used by a provider to submit a claim to Medicaid for reimbursement of services provided to a patient. 2. Non-Reimbursement Affidavit & Memorandum, SHC-1301: This form is used to document services provided to a patient that are not eligible for reimbursement under the Alaska Medical Assistance Program.