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 URAC Accredited Agents
ADDENDUM:
Name of Organization:
Mailing Address (related to this site if
different from above):
Telephone #:
Business Hours:
Name & Title of Person to contact regarding this renewal:
Home/Corporate
Address:
D/B/A (if
applicable):
Site Address:(if
different):
Important: A separate renewal application is required for each additional physical site other than the location
listed below. After submission, notify this office within 30 days of any changes to required information.
I certify that the organization above is currently accredited by URAC and the certification of accreditation is in
good standing.
CONTACT INFORMATION:
Telephone #: Fax #:
E-Mail Address:
Social Security #:
Name: Title:
AFFIRMATION:
Attachments: Copy of Current URAC Accreditation Certification or
Letter from URAC if accreditation is in process of renewal and
Attachment A (Additional UR Sites)
MCC Form 3: Original 10/03
Revised 03/2014
Sworn to and subscribed before me this day of
Notary Public
Authorized Signature: _______________________________________________
(Must be a senior official of the organization)
