PDF Version

TO:   All EPSDT Providers

RE:   Updated EPSDT Referral Form 362

Now Available

Effective May 27, 2025, the Alabama Medicaid Agency (Medicaid) has updated the Early, Periodic, Screening, Diagnostic, and Treatment (EPSDT) Referral Form 362, including a revised pdf fillable version. These forms are now available on Medicaid’s website at the following locations: 

• https://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.5_EPSDT_Forms.aspx
  
  
• https://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.17_Referral_Forms.aspx

The updated Form 362 includes an electronic signature checkbox to confirm a properly applied electronic signature, in compliance with Medicaid requirements. This feature supports providers whose software does not inherently indicate an electronic signature.

Providers are encouraged to use the updated form for all EPSDT referrals moving forward. For additional information on completing the EPSDT Referral Form 362, please refer to Appendix A in the Alabama Medicaid Provider Billing Manual.

Providers with billing questions should contact the Gainwell Technologies Provider Assistance Center at

1-800-688-7989.     

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