Alabama Medicaid Provider Enrollment
Alabama Medicaid Provider Enrollment
Alabama Medicaid Provider Enrollment
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I certify that, to the best of my knowledge, the information supplied in this request is accurate, completeand is hereby released to EDS for the purpose of updating the <strong>Alabama</strong> <strong>Medicaid</strong> service location (s)assigned to the named provider (s).SignatureSignature DatePrint Name of Person Signing FormIndicate Title of Person Signing Form(Signature must be hand written and must be the signature of personnel authorized to make changes for thenamed provider (s). Black ink is required.)Mailing InstructionsPrint a copy of the completed form and mail it to the <strong>Provider</strong> <strong>Enrollment</strong> team. Note: Please print a copyof the form for your records.Mailing Address: 301 Technacenter Drive, Montgomery, AL 36117 or P O Box 241685, Montgomery,AL 36124Facsimile Number: (334) 215-4298If you have any questions concerning this form, please feel free to contact us at 1-888-223-3630 (in<strong>Alabama</strong>) or 334-215-0111 (outside of <strong>Alabama</strong>).Patient 1st 15 Revised September 2009