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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 |
Electronic Visit Verification (EVV) Attestation Form (PDN/Home Health/TA Waiver only) |
All Private Duty Nursing, Home Health, and TA Waiver providers are required to complete this EVV attestation form. EVV is mandated by CMS for all personal care and home health services effective 1/1/24. Providers must complete attestation form as part of the enrollment application process. |
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 |