Alabama Medicaid

Alabama Medicaid 2026 Off-Cycle Revalidation

A variety of online and paper forms are available to providers wishing to enroll or revalidate. 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 - Effective 1/1/26
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 - 4/16/24 Use this form for Enrollment and Revalidation and Administrative Updates
Oct. 2024 - Sept. 2029 PCP Agreement Oct. 2024 - Sept. 2029 PCP Agreement Checklist Oct. 2024 - Sept. 2029 PCP Group Enrollment Agreement Upload Process	(New) ACHN: Alabama Medicaid Primary Care Physician Group Enrollment Agreement - 5/22/24 (New) Instructions and tips on completing the PCP Enrollment Agreement - 5/22/24 (New) Steps to upload the ACHN PCP Group Enrollment Agreement to secure site - 5/22/24
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 - 1/14/26 Use this form for Enrollment and Revalidation
Disclosure Form Tips	Tips for Completing the Provider Disclosure Form - 8/1/24
Disclosure Form	Provider Disclosure Form (Fillable) - 10/31/24 (Use this form for Group/Facility Enrollment - See ALERT)
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 – 2/19/25 Use this form for Enrollment

Revalidations


List	List of Providers Scheduled for Revalidation - 7/26
List	List of Providers Scheduled for Revalidation - 6/26
List	List of Providers Scheduled for Revalidation - 5/26
Instructions	Documentation Requirements - 9/1/13
Instructions	Downloading Provider Revalidation Facsimile
Instructions	Uploading Provider Revalidation
Disclosure Form Tips	Tips for Completing the Provider Disclosure Form - 8/1/24
Disclosure Form	Provider Disclosure Form (Fillable) - 10/31/24 (Use this form for Group/Facility Enrollment - See ALERT)
Provider Agreement	Provider Agreement – 11/30/23 (Use this form for ALL Revalidations)
Individual Disclosure Form	Individual Disclosure Information Form - 9/26/16 (Use this form for Individual Revalidations)

Administrative/Update Forms and Information


"Bump" Form	"Bump" Self-Attestation Form - 4/2/26 (Use this form for Updates)
PDF Fillable Form	Electronic Delivery Form - For providers who wish to electronically receive ALERTS, Provider Notices, newsletters and other communications
Welcome Letter Instructions	Instructions for providers to access their Group and Individual provider welcome letters through the web portal - 12/9/25
CHOW Form	Change of Ownership Form - 8/20/18 (Use this form to notify Medicaid of change)
EFT Agreement	Electronic Funds Transfer (EFT) Agreement 12/6/17 – This form is only applicable if a change of ownership (CHOW) has occurred.
Disenrollment Request Form	Disenrollment Request Form- 4/14/26
Upload Enrollment Update Instructions	Instructions to update enrollment - 12-9-25
Fingerprint Disclosure Statement	Fingerprint - (Medicaid Disclosure Statement for Applicants wishing to change, correct or update their criminal history)
Provider Trading Partner ID Form	Provider Trading Partner ID Form - 12/5/23

Provider Enrollment Forms and Information

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