Patient 1st / Health Home Forms

A variety of online and paper forms are available to recipients and providers for use in conjunction with the Patient 1st Program.  Includes Forms for the Health Home Program. For help in changing PMPs, contact 1-800-362-1504 or Click Here.

 

Forms
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