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P. O. Box 240808 Anchorage AK 99524-0808 907 644-6800 http //medicaidalaska.com HEALTHCARE FORMS ORDER REQUEST Please order a 2-month supply. Ship to Mail to Conduent Allow approximately 4 weeks for delivery. Attention Phone Number AK Medicaid Provider ID Form Requested Description Number UB-04 Institutional Claim Form e.g. Inpatient/Outpatient Hospital Home Health Long Term Care AK-04 Transportation/Accommodation AK-05 Adjustment/Void J430 Dental Claim Form AK-10 Child Health Screening AK-11...
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