Alabama Coordinated Health Network (ACHN) / Primary Care Providers (PCP) Forms

A variety of online and paper forms are available to providers for use in conjunction with the ACHN program.  For help completing the forms, contact the Provider Assistance Center at 1-800-688-7989.

Forms
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 (Revised 10/19)
Form 362 Alabama Medicaid Referral Form (Fillable) (Revised 10/19)
Form 362 - I Instructions for completing Alabama Medicaid Referral Form 362 (Revised 10/19)
Form 391 PCP Override Request Form (Revised 11/19)
Disenrollment Request Form

Disenrollment Request Form- 10/11/19

Immunization Documentation Link to ADPH website regarding Pediatric, Adolescent and Adult Immunization Record