Provider Enrollment Forms and Information

A variety of online and paper forms are available to providers wishing to enroll or re-enroll.  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 - 12/13/18
FAQs Enrollment Application Web Portal - Frequently Asked Questions about using the Portal  
EFT Agreement Electronic Funds Transfer EFT Agreement - 12/6/17   Use this form for Re-Enrollment and CHOW applications
ERA Agreement Electronic Remittance ERA Agreement - 12/6/17   Use this form for Enrollment and Re-Enrollment
EPSDT Agreeement EPSDT Agreement - 9/26/16    Use this form for Enrollment and Re-Enrollment and Administrative Updates  
PCP Agreement ACHN: Alabama Medicaid Primary Care Physician Group Enrollment Agreement - 5/10/19
PCP Agreement Checklist Instructions and tips on completing the PCP Enrollment Agreement - 7/8/19
PCP Group Agreement Update Form Primary Care Physician (PCP) Groups that are currently enrolled in the Alabama Coordinated Health Network (ACHN) program and would like to add their individual providers or mid-level extenders to the enrollment. - 7/10/19
Physiological Lab Form Physiological Lab Certification - 10/27/17  Use this form for Enrollment
Plan First Agreement Plan First Program Agreement - 10/27/17   Use this form for Enrollment and Re-Enrollment and Administrative Updates
Tax Form W-9 Tax Form     Use this form for Enrollment
Corporate Form Corporate Board of Directors Resolution - 10/27/17  Use this form for Enrollment and Reenrollment
Provider Agreement Provider Agreement  - 10/19/18   Use this form for Re-Enrollment
Disclosure Form Provider Disclosure Form -  12/1/19  Use this form for Enrollment, Re-Enrollment and Administrative Updates
Telemedicine Agreement Telemedicine Services Agreement -- Combines Provider Agreement and Recipient Consent Form -  9/26/16  Use this form for Enrollment and Administrative Updates
Civil Rights Form Civil Rights Compliance Information Request Package – 3/14/17 - Use this form for Enrollment

Re-Enrollment
List List of Providers Scheduled to Re-Enroll - 11/19
List List of Providers Scheduled to Re-Enroll - 10/19
Instructions Documentation Requirements - 9/1/13
Instructions Downloading Provider Reenrollment Facsimile
Individual Disclosure Form Individual Disclosure Information Form - 9/26/16 (Use this form for Reenrollment)
Administrative/Update Forms and Information
"Bump" Form "Bump" Self-Attestation Form - 9/9/19 (Use this form for Updates)
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)
Disenrollment Request Form

Disenrollment Request Form- 10/11/19

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)