Alabama Administrative Code
Title 560 - ALABAMA MEDICAID AGENCY
Chapter 560-X-6 - PHYSICIANS PROGRAM
Section 560-X-6-.07 - Enrollment Of Out Of State Providers
Universal Citation: AL Admin Code R 560-X-6-.07
Current through Register Vol. 43, No. 02, November 27, 2024
(1) An outofstate physician who wishes to participate in the Alabama Medicaid Program must enroll with the Alabama Medicaid Program and be assigned a provider identification number. To do so, the physician should send a written request to Medicaid's fiscal agent, Provider Enrollment Division. The following information must be included in the enrollment application:
(a) Name;
(b) Address of Place of Business;
(c) Provider Type and specialty;
(d) Social Security Number;
(e) Federal Employer Identification
Number;
(f) Medicaid license
Number;
(g) Personal Historical
Data; and
(h) Original Provider
Signature.
Author: Janet B. Young
Statutory Authority: Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.; State Plan.
Disclaimer: These regulations may not be the most recent version. Alabama may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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