Alabama Department of Public Health
Bureau of Health Provider Standards
Division of Managed Care Compliance
201 Monroe Street, Suite 710
Montgomery, AL 36104
(334) 206-5366
Renewal Application for Non-URAC Agents
Name of Organization:
Mailing Address (related to this site
if different from above):
Phone #:
Business Hours:
Name & Title of Person to contact regarding this renewal:
Home/Corporate
Address:
D/B/A (if
applicable):
UR Site Address:(if
different from Corporate):
Important: The certification period for Non-URAC agencies begins 1 July and ends 30 June each year. A separate
renewal application is required for any additional physical site other than the corporate office.
Phone #: Fax #: E-Mail Address:
After submission, notify this office within 30 days of any changes to required information.
CONTACT INFORMATION:
$1,000 fee made payable to "Alabama Department of Public Health
Enclosures:
Attachment A with contact person information for each UR Site. Each UR site requires a separate renewal application
Policy Attestation Statement
Policy & Procedure Checklist Form: Red line comparisons of revised policies. Submit clean copies of revised/new policies
A copy of the complaint and appeal process.
Send red line comparison documents with the clean original for review and approval.
ADDENDUM:
I do solemnly swear or affirm that I am familiar with the laws of Alabama relating to utilization agents; that I have complied
with all of the requirements of Code of Alabama, §27-3A-5; that all of the foregoing information, the addendum, and the
documentary evidence submitted is true, complete, and correct to the best of my knowledge and belief.
Name: Title:
Social Security #:
Authorized Signature: _________________________________________
( Must be a senior official of the organization)
AFFIRMATION:
Sworn to and subscribed before me this day ______________________________
____________________________________________________
Signature and Seal of Notary Public
MCC Form 4: Original 10/03
Revised 03/2014
