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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 1/23/23 |
| 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 Revalidation and CHOW applications |
| ERA Agreement |
Electronic Remittance ERA Agreement - 12/6/17 Use this form for Enrollment and Revalidation |
| EPSDT Agreement |
EPSDT Agreement - 9/26/16 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 - 12/10/20 Use this form for Enrollment and Revalidation 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 Revalidation |
| Provider Agreement |
Provider Agreement - 10/19/18 Use this form for Revalidation |
| Disclosure Form |
Provider Disclosure Form - 12/1/19 Use this form for Enrollment, Revalidation 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 |