Demographic Updates 

Ambetter of Alabama is committed to providing our providers with the best tools possible to support their administrative needs. We have created an easy way for you to request updates to your information and ensure we receive what we need to complete your request in a timely manner. If you are an existing participating practitioner, fill out the form below with all necessary details, including all required documentation. When selecting the type of update, please review the critical requirements in bold to ensure accuracy in processing your request. Please also be aware that omitting necessary documentation may result in a delay in processing your request. 

Alabama Demographic Update Roster

Are you making a change for a required *
Please no dashes “- “
Type of Update required *

Accepting Patient Status

Please indicate your patient panel status required *

Email Address

Do you want to add or remove current email address? required *

Name Change (Practitioners Only)

Please upload a copy of supporting, legal documentation for the practitioner’s name change AND an updated medical license using Supporting Document upload button. 

Office Hours

Please enter the service location address that the change in office hours applies to

Please enter the office hours for each day of the week

Phone/Fax Number

Please enter the service location address that the change in phone/fax numbers apply to

Service Location (Add/Term)

Select which option is needed for this update required *

Please enter the service location address

Specialty/Taxonomy Update

Please upload a copy of training and education using Supporting Document upload button.

W-9 Submission

Please upload a copy of the W-9, dated within the last 12 months, using the Supporting Document upload button.