Forms for Medicaid Applicants and Recipients

A variety of online and paper forms are available to applicants, recipients and sponsors.  For help in applying for Medicaid, contact 1-800-362-1504.

 

Applications
Apply Online Go online to apply for Medicaid for children, pregnant women, parents or other caretakers, or Plan First
Joint Paper Application Paper application to apply for health coverage for children, pregnant women, parents or other caretakers, or Plan First
Appendix A Goes along with the paper application - To be filled out if someone in the household is eligible for health coverage from a job
Appendix B Goes along with the paper application - To be used if the applicant or family member is American Indian or Alaska Native
Appendix C Goes along with the paper application - To be used if the applicant wishes to give a trusted person permission to help with the application (Also known as an authorized representative)
Spanish - Paper Application Paper application to apply for health coverage for children, pregnant women, parents or other caretakers, or Plan First
Appendix A -Spanish Goes along with the paper application - To be filled out if someone in the household is eligible for health coverage from a job
Appendix B -Spanish Goes along with the paper application - To be used if the applicant or family member is American Indian or Alaska Native
Appendix C -Spanish Goes along with the paper application - To be used if the applicant wishes to give a trusted person permission to help with the application (Also known as an authorized representative)
Form 204/205 Fillable application to use when applying for Elderly & Disabled programs, including nursing home care and home and community-based waivers
Tips for Applying Tells applicants what information is needed when applying for Nursing Home (Institutional) Medicaid
Form 262 Qualifying Income Trust Packet for Medicaid applicant to is entering the nursing home and has excess income
Form 234 To notify Medicaid of important information relating to a claimant - fillable
Form 211 Fillable application for help in paying Medicare premiums (Medicare Savings Program)
Form 357 Plan First Application for people without children - 7/15 - fillable
Form 357 Plan First Application for family planning services only - fillable
Form 284 Used to enroll children of Medicaid-eligible mothers (including SSI mothers) from birth to the first birthday
Medicaid Addresses List of mailing addresses for applications
Helpful Forms for Recipients
Form 202 Form used if a Medicaid recipient or applicant wishes to give a trusted person permission to represent or help them (Also known as an authorized representative)
Form 295 Fillable form used to tell Medicaid about changes in a recipient's status, such as a change in address, income, or marital status
   
Third Party Benefit Coordination Forms
Online HIPP Application Go online to apply for Medicaid's Health Insurance Premium Payment program (HIPP)
Or print out a paper copy to fill out.
Form 3P-1 Fillable form to request Medical Records
Form 3P-2 Fillable form to report changes in insurance coverage
Estate Recovery Forms
Estate Administrator Form Fillable form to designate a beneficiary of patient trust funds   -  Return to Alabama Medicaid Agency/Estate Recovery Unit 
Instructions - Estate
Administrator Form
Estate Administration Designation Form Instructions
   
Patient 1st Forms
Form 354 Request for Newborn Assignment - Fax or Mail
Form 393 Grievance Form to tell Medicaid if you have a complaint about a Patient 1st provider
Form 349 -Mail Fillable form used to change your Patient 1st primary medical provider (PMP) by Mail
Form 349 - Fax Fillable form used to change your Patient 1st primary medical provider (PMP) by Fax