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Uniform Provider Application

The Alabama Uniform Provider Application was developed through a cooperative effort of the Alabama Hospital Association, Medical Association of the State of Alabama,  Alabama Association of Medical Staff Services, Alabama Association of Health Plans, Alabama Medicaid Agency and Medical Group Management Association of Alabama. 

Click here to print a blank Alabama Uniform Provider Application or scroll down for more information.

ATTENTION HOSPITALS
The Alabama Hospital Association is maintaining a list of hospitals that accept the Alabama Uniform Provider Application. If your hospital is not currently using the uniform application, but would like to consider it,  click here to review the application. Once you have reviewed the application, click the appropriate link below to send an e-mail stating if your hospital will accept the uniform application. (Indication "YES" implies your permission for your hospital's name to be listed on-line.)

  >> Yes, our hospital will accept the Alabama Uniform Provider Application.
  >> No, our hospital WILL NOT accept the Alabama Uniform Provider Application.

Organizations that will accept the application
The following hospitals have indicated they will accept the Alabama Uniform Provider Application. This list continues to grow.

>> Baptist Health System, Birmingham
>> Chilton Medical Center, Clanton 
>> Community Hospital, Tallassee 
>> Coosa Valley Medical Center, Sylacauga 
>> Crestwood Medical Center, Huntsville

>> D. W. McMillan Memorial Hospital, Brewton 
>> Huntsville Hospital, Huntsville 
>> Jackson County Hospital, Scottsboro 
>> Marshall Medical Center North, Guntersville
>> Marshall Medical Center South, Boaz
>> Red Bay Hospital, Red Bay 
>> Russell Medical Center, Alexander City

>> Southeast Alabama Medical Center, Dothan 
>> Wedowee Hospital, Wedowee

Currently the Alabama Uniform Provider Application is accepted by these plans:

>> Blue Cross Blue Shield of Alabama
>> Alabama Medicaid Agency
>> Viva Health
>> HealthSpring of Alabama
>> Direct Care America (Ohio)
>> North Alabama Managed Care, Inc. (NAMCI)
>> MultiPlan
>> ppoNEXT
>> hpo, ltd.
>> PHCS.
>> USA MCO

Completing the Application
If planning to be credentialed by Blue Cross and Blue Shield of Alabama, you may click here to fill out the Alabama Uniform Provider Application electronically via the Blue Cross Web site. After completion of the on-line application for Blue Cross, it may also be printed and submitted to other participating parties.

If you do not intend to be credentialed by Blue Cross and Blue Shield of Alabama, you may click here to print a blank Alabama Uniform Provider Application, which can then be completed and submitted to participating parties.

In order to print the blank form, you must have Adobe Acrobat Reader installed on your computer. If you do not already have Adobe Acrobat installed, you may install it for free by clicking here.