1. (1) An out-of-state 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:

   1. (a) Name;
   2. (b) Address of Place of Business;
   3. (c) Provider Type and specialty;
   4. (d) Social Security Number;
   5. (e) Federal Employer Identification Number;
   6. (f) Medicaid license Number;
   7. (g) Personal Historical Data; and
   8. (h) Original Provider Signature.

Author: Janet B. Young

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

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