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 8/2019)
Form 362 - I Instructions for completing “The Alabama Medicaid Referral Form 362 (revised 8/2019)
Form 391 PCP Override Request Form (revised 9/2019)
ACHN Disenrollment Request Form

Disenrollment Request Form- 09/09/2019 (Use this form to notify Medicaid of intent to disenroll from ACHN, effective 10/1/2019)

Immunization Documentation Link to ADPH website regarding Pediatric, Adolescent and Adult Immunization Record
PCP Group Agreement Update Form Primary Care Physician (PCP) Groups that are currently enrolled in the Alabama Coordinated Health Network (ACHN) program and would like to add their individual providers or mid-level extenders to the enrollment. - 7/10/19