Get Al Provider Disclosure Form 2023-2025

Completing the AL Provider Disclosure Form online is a crucial step for providers seeking to establish or update their enrollment. This guide will walk you through each section of the form, ensuring that you understand the requirements and can submit your information accurately.

Follow the steps to successfully fill out the AL Provider Disclosure Form online.

1. Click the 'Get Form' button to obtain the AL Provider Disclosure Form and access it in your preferred online editor.
2. Select the purpose of the form by checking the appropriate box. You can choose from options such as Initial Enrollment, Revalidation, or Update. Be sure to fill in your National Provider Identifier (NPI) number as required in the designated field.
3. Provide your name along with your title in the spaces provided.
4. List any previous home and business addresses, if applicable, again using 'N/A' for any non-applicable questions.
5. Detail any individuals with an ownership or controlling interest in the entity by listing their names and addresses. This includes relatives if they possess a 5% or greater interest. Use additional sheets as needed.
6. Indicate whether you have any familial relationships with other owners, officials, or shareholders by selecting 'Yes' or 'No' and elaborating as necessary if the response is affirmative.
7. Document any business transactions exceeding $25,000 in the past 12 months, providing the full legal name, address, amount, and your relationship to the suppliers or subcontractors.
8. Answer whether your license is currently suspended or restricted and provide necessary explanations if applicable.
9. State whether you have ever been convicted of a crime, excluding minor traffic violations, and detail any relevant information if the answer is 'Yes'.
10. Conclude by answering whether you have outstanding criminal fines or restitution orders, providing details where necessary.
11. Once all information has been filled out, review the form for accuracy, then save changes, download a copy, print, or share the completed form online as needed.

Begin filling out the AL Provider Disclosure Form online today to ensure your compliance and smooth enrollment process.