UR 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 700
Physical Address: 201 Monroe Street, Montgomery, AL 36104
Mailing Address: P. O. Box 303017, Montgomery, AL 36130-3017
Phone: (334) 206-5140
Fax: (334) 206-5219

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 ChecklistAnnual Policy Attestation Statement (Non-URAC)

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


Page last updated: May 19, 2017