Alabama Department of Public Health
Bureau of Health Provider Standards
Division of Managed Care Compliance
201 Monroe Street, Suite 710
Montgomery, Alabama 36104
(334) 206-5366
Attachment A
Additional or Satellite Sites Conducting Utilization Review for Alabama
Use additional sheet(s) if necessary
There are no Additional or Satellite Sites
D/B/A (if applicable):
Site Address:
Contact Person:
Business Hours:
Phone #:
Fax #:
E-Mail Address:
Name of Organization:
Name of Organization:
Name of Organization:
Name of Organization:
D/B/A (if applicable):
D/B/A (if applicable):
D/B/A (if applicable):
Contact Person:
Contact Person:
Contact Person:
Site Address:
Site Address:
Site Address:
Business Hours:
Business Hours:
Business Hours:
Phone #:
Phone #:
Phone #:
E-Mail Address:
E-Mail Address:
E-Mail Address:
Fax #:
Fax #:
Fax #:
MCC Form #2: Original 09/2003
Revised 03/2014