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.


Effective December 7
, 2016, providers will be able to upload or fax Enrollment supporting documentation via the “Forms” menu of the Web Portal. The following will be supported: Enrollment Update, EFT, OPR, and Re-Enrollment Update. Enrollment supporting documentation will continue to be accepted in paper format until January 2, 2017. After that date, supporting documents received on paper will be returned to the provider. Refer to the 11/01/2016 Provider Alert for more details.

 

Enrollment
Apply Online Electronic Provider Enrollment Application for Web Portal      Click here for Web Portal Training Manual
Instructions Medicaid Participation Requirements - 5/1/17
FAQs Enrollment Application Web Portal - Frequently Asked Questions about using the Portal  
EFT Agreement Electronic Funds Transfer EFT Agreement - 7/14/15   Use this form for Enrollment and Re-Enrollment
ERA Agreement Electronic Remittance ERA Agreement - 7/14/15   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  
Patient 1st Enrollment Agreement Patient 1st Individual Provider Enrollment Agreement. For All Patient 1st Providers - 2/2/15   Use this form for Enrollment
Physiological Lab Form Physiological Lab Certification - 1/5/12  Use this form for Enrollment
Plan First Agreement Plan First Program Agreement - 9/26/16   Use this form for Enrollment and Re-Enrollment and Administrative Updates
Signature Form Signature Page for Provider Web Portal Application- 1/5/12    Use this form for Enrollment
Tax Form W-9 Tax Form     Use this form for Enrollment
Corporate Form Corporate Board of Directors Resolution - 9/26/16  Use this form for Enrollment and Reenrollment
Provider Agreement Provider Agreement  - 9/26/16   Use this form for Enrollment and Re-Enrollment
Disclosure Form Provider Disclosure Form -  12/9/16  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 - 9/17
List List of Providers Scheduled to Re-Enroll - 8/17
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 - 9/21/16 (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 - 10/1/2015 (Use this form to notify Medicaid of change)
Disenrollment Form Disenrollment Request Form - 5/24/17 (Use this form to notify Medicaid of intent to disenroll)
Out-of-State Form Out-of-State ASC and Hospital to update enrollment status - 2/2/12 (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)