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.

PCMH Form Patient-Centered Medical Home (PCMH) Recognition Attestation Form - 2/1/24
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 (includes instructions for completing the Alabama Medicaid Referral Form)
Form 362 Alabama Medicaid Referral Form (Fillable)
Form 391 PCP Override Request Form (Revised 12/7/20)
Disenrollment Request Form

Disenrollment Request Form- 12/7/20

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