|
|
| PHY-96-2 |
Certification and Documentation for Abortion (providers only) - Fillable - Updated 12/7/20 Note: On 10/26/16 changes were implemented to enable providers to upload or fax Abortion Consent Forms and supporting documentation via the Forms menu of the Web Portal. Effective November 28, 2016, Abortion Forms and supporting documentation received on paper will be returned to the provider. Review the October 2016 Provider Insider for details. |
| PHY-81243, EFFECTIVE 10/1/2025 |
Hysterectomy Consent (providers only) - Fillable - Updated 10/1/2025 Note: On 10/1/2025, changes were implemented to the Hysterectomy Consent Form and administrative review process. Please see the Provider ALERT issued on September 18, 2025 for additional details (https://medicaid.alabama.gov/alert_detail.aspx?ID=16625). The October 2025 edition of Chapter 28 of the Provider Billing Manual has been updated to reflect these changes. Providers must use the updated consent form for hysterectomy procedures performed on or after October 1, 2025.
|
| Form 193 |
Sterilization Consent (providers only) - Fillable - Updated 9/26/16 Note: On 10/26/16 changes were implemented to enable providers to upload or fax Sterilization Consent Forms and supporting documentation via the Forms menu of the Web Portal.. Effective November 28, 2016, Sterilization Forms and supporting documentation received on paper will be returned to the provider. Review the October 2016 Provider Insider for details. |
| Form 193 Spanish |
Sterilization Consent (providers only) - Spanish |
| Form 193-I |
Instructions for Completing Sterilization Consent Form |
| 193- Numbered Fields |
For Completing Sterilization Consent Form |
| 193-F Packet |
Women's Sterilization Consent Educational Packet |
| Form 193-F Packet Spanish |
Instructions for Completing Sterilization Consent Form – Spanish |
| 193-M Packet |
Men's Sterilization Consent Educational Packet |
| 193-M Packet Spanish |
Men's Sterilization Consent Educational Packet - Spanish |
| Form 154 |
Agreement between Nursing Facility and Resident/Representative for Care |
| Form 391 |
Opioid Dependence Treatment Agreement and Patient Consent Form - Effective 7/3/17 |
| Form 392 |
Patient Consent Form for Hepatitis C Agents - 10/1/22 |
| Form 138-FP |
Family Planning Consent Form - Providers may use their own form as long as all required information is contained in the provider's form |
| Form 175-FP |
Family Planning Home Visit (includes consent for visit by recipient) |
| Form 385 |
Targeted Case Management Consent - 1/3/22 |
| Form 388 |
Private Duty Nursing/Technology Assisted Waiver Agreement for Care |
| PHE-91-30-1 |
Biographical Data Sheet/Consent Form |
| Informed Consent |
Gateway to Community Living - Informed Consent With Options Counseling Form - For Case Managers |
| |
|