Get Appreciate Your Interest In The Medicaid Program, And Welcome The Opportunity To Work With You To

This guide provides a step-by-step approach to completing the Appreciate Your Interest In The Medicaid Program form online. By following these instructions, you can ensure that your application is filled out correctly and submitted without issues.

Follow the steps to complete your Medicaid application form successfully.

1. Click the ‘Get Form’ button to access the form and open it in the online editor.
2. Identify your provider type and specialty on the Alabama Medicaid Provider Type and Specialty Identification form. Circle the appropriate provider type and, if applicable, up to five specialty codes.
3. Refer to the Alabama Medicaid Participation Requirements in the Reference Materials section to ensure you meet the minimum enrollment requirements for participation in the Alabama Medicaid Program.
4. Complete the Alabama Medicaid Provider Enrollment Application. Ensure that all fields are filled out accurately and clearly, using black or blue ink only if printing manually.
5. Read, sign, and complete the Alabama Medicaid Agency Provider Agreement form. Ensure that all required signatures are original.
6. Review Section III, Required Attachments, of your enrollment application. Include any applicable attachments as specified.
7. Check the forms in the Additional Enrollment Forms section to determine which are applicable to your situation. At a minimum, complete the W-9 and Electronic Funds Transfer Agreement forms.
8. Confirm that you have completed the Required Forms Check List located in the Reference Materials section to ensure that all documentation is accurate and complete.
9. Make a copy of the completed application for your records. Send the original application via mail to the provided addresses for EDS Provider Enrollment.

Complete your Medicaid enrollment application online today for efficient processing.