EPSDT Forms

Referrals are frequently used in the EPSDT program to faciliate diagnosis and treatment of various health conditions in Medicaid-enrolled children.
Forms
Form 172 EPSDT Child Health Medical Record (optional form)
Form 362 Medicaid Referral Form
(includes instructions for completing the Alabama Medicaid Referral Form)
Form 362 Medicaid Referral Form - Fillable  
EPSDT Provider Agreement EPSDT Provider Enrollment Form