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Utilization Review Forms

An organization seeking initial certification or renewal of their current certification in Alabama, may complete and download the necessary forms from this site. Forms are to be mailed to:

Managed Care Compliance
Alabama Department of Public Health
Bureau of Health Provider Standards
The RSA Tower, Suite 710
Physical Address: 201 Monroe Street, Montgomery, AL 36104
Mailing Address: P. O. Box 303017, Montgomery, AL 36130-3017
Phone: (334) 206-5988
Fax: (334) 206-2067

Please consult the Utilization Review Law for information regarding organizations requiring certification, or call  (334) 206-5988.

Initial Certification:

A.  Organizations holding certification from the Utilization Review Accreditation Commission (URAC) and are seeking initial certification in Alabama must submit the following forms (containing original signatures):

1.  Utilization Review (UR) Application
2.  Attachment A
3.  Copy of current URAC Certificate specific to Health Utilization Management Standards

B.  Non-URAC organizations must submit a check for $1,000 made payable to the "Alabama Department of Public Health" and the following forms (containing original signatures): 

1. UR Application
2.  Attachment A
3.  Policy and Procedure Checklist

Renewal Certification:
A.  URAC accredited agencies must submit the following:

1.  Renewal application form for "URAC Accredited Agents"
2.  Attachment A
3.  Copy of current URAC certificate specific to Health Utilization Management Standards or a letter from URAC if accreditation is in process of renewal.  When the URAC certificate is issued.  Must forward a copy to this office.
4.  For agencies with multiple sites, there must be a renewal application for each site.

B.  Non-URAC accredited organization must submit the following:

1.  Renewal application form for Non-URAC accredited agents
2.  Attachment A
3.  Policy and Procedure Checklist
4.  Annual Policy Attestation Form


Forms:
Application for Certification as a UR Review Agent
Attachment A 
Renewal application for URAC Accredited Agents
Renewal application for Non-URAC Accredited Agents
Policy and Procedure Checklist
Annual Policy Attestation Statement (Non-URAC)

Organizations may complete and download the required forms and submit renewal information in advance of Public Health's notification.


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