Part IV: Filing Fee
Organizations that are accredited by URAC are exempt from paying a filing fee.
Non-URAC organizations must submit an one thousand dollars ($1,000) filing fee made payable to the Alabama
Department of Public Health.
AFFIRMATION
ADDENDUM TO APPLICATION FOR CERTIFICATION OR RENEWAL
OF CERTIFICATION AS A UTILIZATION REVIEW AGENT
Code of Alabama §30-3-194 requires state agency to collect applicant social security number for the issuance or
renewal of licenses; certificates, or permits. This information will be held confidential and will not be provided as
public record. Applicants and renewing utilization review agents not providing this information will be denied the
privilege of conducting utilization review in Alabama.
Name of Organization:
Name of Applicant (Type or Print):
Applicant's Social Security Number*:
*(Federal ID numbers or company ID numbers are not acceptable):
Signature of Applicant: _________________________________________________________________
(Applicant should be the senior official of the organization)
Notary Public: ___________________________________________________
Subscribed and sworn to before me this day of
I do solemnly swear or affirm that I am familiar with the laws of Alabama relating to utilization review agents; that I
have complied with all of the requirements of the Code of Alabama §27-3A-5; that all of the foregoing information,
the addendum, and documentary evidence submitted is true, complete to the best of my knowledge and belief.
Title of Applicant:
