Provider Enrollment Forms and Information

A variety of online and paper forms are available to providers wishing to enroll or revalidate.  For help enrolling as a Medicaid provider, contact 1(888) 223-3630 or (334) 215-0111.


Providers should submit any Enrollment Updates via the "Forms" menu of the provider secure portal effective January 2, 2017.  Faxed requests will not be accepted.

 

Enrollment
Apply Online Electronic Provider Enrollment Application for Web Portal  Click here for Web Portal Training Manual
Instructions Medicaid Participation Requirements - Effective 1/1/24
FAQs Enrollment Application Web Portal - Frequently Asked Questions about using the Portal  
ERA Enrollment Application Electronic Remittance Advice (ERA) Application  - 12/6/17 Use this form for Enrollment and Revalidation
EPSDT Agreement EPSDT Agreement - 11/21/23 Use this form for Enrollment and Revalidation and Administrative Updates  
PCP Agreement ACHN: Alabama Medicaid Primary Care Physician Group Enrollment Agreement - 5/28/21
PCP Agreement Checklist Instructions and tips on completing the PCP Enrollment Agreement - 5/28/21
Physiological Lab Form Physiological Lab Certification - 10/27/17 Use this form for Enrollment
Plan First Agreement Plan First Program Agreement - 11/21/23 Use this form for Enrollment and Revalidation and Administrative Updates
Tax Form W-9 Tax Form - 11/21/23 Use this form for Enrollment
Corporate Form Corporate Board of Directors Resolution - 11/21/23 Use this form for Enrollment and Revalidation
Disclosure Form Provider Disclosure Form - 11/21/23 (Use this form for Group/Facility Enrollment)
Telemedicine Agreement Telemedicine Services Agreement -- Combines Provider Agreement and Recipient Consent Form - 11/21/23 Use this form for Enrollment and Administrative Updates
Civil Rights Form Civil Rights Compliance Information Request Package – 11/21/23 Use this form for Enrollment

Revalidations
List List of Providers Scheduled for Revalidation - 11/23
List List of Providers Scheduled for Revalidation - 10/23
List List of Providers Scheduled for Revalidation - 9/23
Instructions Documentation Requirements - 9/1/13
Instructions Downloading Provider Revalidation Facsimile
Instructions Uploading Provider Revalidation
Disclosure Form Provider Disclosure Form – 11/21/23 (Use this form for Group/Facility Revalidations)
Provider Agreement

Provider Agreement – 11/30/23 (Use this form for ALL Revalidations)
Individual Disclosure Form Individual Disclosure Information Form - 9/26/16 (Use this form for Individual Revalidations)
Administrative/Update Forms and Information
"Bump" Form "Bump" Self-Attestation Form - 8/16/22 (Use this form for Updates)
Fillable Form Electronic Delivery Form - For providers who wish to electronically receive ALERTS, Provider Notices, newsletters and other communications  
PDF Fillable Form Electronic Delivery Form - For providers who wish to electronically receive ALERTS, Provider Notices, newsletters and other communications  
CHOW Form Change of Ownership Form - 8/20/18 (Use this form to notify Medicaid of change)
EFT Agreement Electronic Funds Transfer (EFT) Agreement 12/6/17 – This form is only applicable if a change of ownership (CHOW) has occurred.
Disenrollment Request Form

Disenrollment Request Form- 12/7/20
Out-of-State Form Out-of-State ASC and hospital form to update enrollment status - 1/19/18 (Use this form to update information at Medicaid)
Provider File Update Form Provider File Update Request Form - This fillable form is used to update the provider's information on file. 
Fingerprint Disclosure Statement Fingerprint - (Medicaid Disclosure Statement for Applicants wishing to change, correct or update their criminal history)
Provider Trading
Partner ID Form		 Provider Trading Partner ID Form - 12/5/23

 

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