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| PCMH Form |
Patient-Centered Medical Home (PCMH) Recognition Attestation Form - 2/1/24 |
| Form 172 |
EPSDT Child Health Medical Record |
| Form 284 |
To enroll children of Medicaid-eligible mothers (including SSI mothers) from birth to first birthday - with instructions |
| Form 362 |
Alabama Medicaid Referral Form (includes
instructions for completing the Alabama Medicaid Referral Form) |
| Form 362 |
Alabama Medicaid Referral Form (Fillable) |
| Form 391 |
PCP Override Request Form (Revised 12/7/20) |
| Disenrollment Request Form |
Disenrollment Request Form- 12/7/20
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| Immunization Documentation |
Link to ADPH website regarding Pediatric, Adolescent and Adult Immunization Record |