Alabama Medicaid Provider Enrollment

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MEDICAID / PATIENT 1 STPHYSICIAN ENROLLMENT FORMSECTION I – General InformationThis application is to be completed for participation in the Patient 1 st Program. If applying as a group or clinic, please answerquestions below on behalf of the group or clinic. If you have questions, please consult the Patient 1 st Manual or call EDS’ ProviderEnrollment Department at 1-888-223-3630.Are you enrolling as an: INDIVIDUAL GROUP/PRACTICE FQHC (clinic) RHC (clinic)Has this practice or anyone associated with this practice been terminated or sanctioned by either Medicare orMedicaid? Yes No – If answering Yes, please send documentation containing details.Are you associated with an academic teaching facility? Yes NoSpecialty: Family Practice General Practice Pediatrician OB/GYN Internal MedicineOther:Name:Group/Clinic Name:*Individual NPI:*Organizational NPI:* Indicate NPI number only if this application is to enroll an existing enrolled location in the Patient 1 st Program. If this is a newenrollment, please mark N/A for that field.Contact for Patient 1 st referral:Contact person’s phone number:Physical Address:Mailing Address:Credentialing Contact & Phone Number:NOTE: The mailing address indicated above will be applied to the file of the provider for which this application is completed. Only Patient 1 stCorrespondence will be mailed to the address given.SECTION II – Participation DetailsPMPs have the ability to decide the parameters under which they wish to participate in the Patient 1 st Program. Changes to such parametersmust be communicated in writing and can be faxed to EDS’ Provider Enrollment Department at 334-215-4298.Distance/Number of Patients: (Max Distance is 75 Miles)Distance Number of Patients Patient Age Criteria(i.e. 5-8)TotalDo you wish to be publishedon Patient 1 st List?Y NNOTE: Total caseload cannot exceed 1200 unless enrolling as a group or clinic. Up to two physician extenders (mid-level associates) can beutilized for a max caseload of 2000. For caseloads greater than 2000, justification must be submitted with application.Mid-Level Practitioners:Indicate Physician Extender (Mid-Level Associate) Name(s) and NPINumber(s) below:NOTE: NPI numbers listed for Physician Extender(s) indicated should be associated to the site of practice to which these patients will beassigned.Patient 1st 2 Revised September 2009
Section II (continued)Admitting Privileges:Will you be admitting your own patients? Yes If yes, please indicate hospital name(s) below. No If no,please complete attachment A of contract.EPSDT:Are you currently enrolled in the EPSDT program? Yes NoIf you are not currently enrolled, will you be doing your own EPSDT screenings? Yes NoIf Yes, please be certain an EPSDT agreement is completed and submit it with a copy of your current CLIAcertificate.If No, you must designate an EPSDT enrolled provider to do your screening for you by completing attachment Bof the contract.24/7 Coverage:List your phone number for patient 24-hour access:Describe your after-hours coverage below:FTE Status:How many hours per week do you practice at this location?SECTION III – Group or Clinic DetailsPlease provide the following information on the members of the group or clinic. It is acceptable to attach additional pages if necessary. Thisinformation will be used to calculate the total allowable caseload for the group or clinic.NOTE: This section is applicable to groups or clinics only.Physician/Practitioner Name NPI Number Hours per week, thePhysician/Practitioner willbe working at this site.Indicate if Physician orPractitioner.I am applying to participate as a primary care provider in the Patient 1 st Program sponsored by the AlabamaMedicaid Agency. I have read and understand the Patient 1 st Provider Manual, the Agreement for Participationand have completed all the necessary forms, including the case management fee components.Signature:Date:Business Title/Position:Patient 1st 3 Revised September 2009
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Page 15: I certify that, to the best of my k

Alabama Medicaid Provider Enrollment

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