Ala. Admin. Code r. 560-X-6-.07

Current through Register Vol. 43, No. 02, November 27, 2024

Section 560-X-6-.07 - Enrollment Of Out Of State Providers

(1) An outofstate physician who wishes to participate in the Alabama Medicaid Program must enroll with the Alabama Medicaid Program and be assigned a provider identification number. To do so, the physician should send a written request to Medicaid's fiscal agent, Provider Enrollment Division. The following information must be included in the enrollment application:

(a) Name;

(b) Address of Place of Business;

(c) Provider Type and specialty;

(d) Social Security Number;

(e) Federal Employer Identification Number;

(f) Medicaid license Number;

(g) Personal Historical Data; and

(h) Original Provider Signature.

Author: Janet B. Young

Ala. Admin. Code r. 560-X-6-.07

Rule effective October 1, 1982. Amended: effective May 9, 1984; March 12, 1987. Amended: Filed December 7, 1994; effective January 12, 1995.

Statutory Authority: Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.; State Plan.