|
|
| Form 284 |
To enroll children of Medicaid-eligible mothers (including SSI mothers) from birth to first birthday - with instructions |
| Online Change Form |
To change your personal doctor online |
| Form 349 |
To change your personal doctor - fillable - Fax |
| Form 349 |
To change your personal doctor - fillable - Mail |
| Form 354 |
Newborn Assignment - fillable |
| Form 362 |
Alabama Medicaid Referral Form - fillable |
| Form 362 - I |
Instructions for completing Form 362 |
| Form 379 |
Request for patient education through Targeted Case Management |
| Form 391 |
Override Request |
| Form 392 |
Medical Exemption |
| Form 393 |
Grievance Form - to tell Medicaid if you have a complaint about a Patient 1st provider |
| Form 450 |
To request dismissal of patient from PMP panel - Updated 11/21/11 |
| Patient 1st PMP Update Form |
For Patient 1st program-enrolled physicians who want to update their provider panel |
| Form 172 |
EPSDT Child Health Medical Record |
| Immunization Forms |
ADPH website regarding Pediatric, Adolescent and Adult Immunization Record |