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Verification of Enrollment

 
To be eligible for enrollment, your practice must have its primary location in Alabama or in a qualifying county in an adjacent state.
Primary Practice State:* 
Primary Practice County:* 
Not Required for AL  


(Please provide all of the following values so that we can verify your current enrollment status.)
Provider First Name:* 
Provider Last Name:* 
SSN:* 
Date of Birth:*  (mmddyyyy)
Individual NPI:*