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EPSDT Forms
Referrals are frequently used in the EPSDT program to faciliate diagnosis and treatment of various health conditions in Medicaid-enrolled children.
Forms
Form 172
EPSDT Child Health Medical Record (optional form)
Form 362
Medicaid Referral Form
Form 362
Medicaid Referral Form - Fillable
362 - I
Instructions for completing the Alabama Medicaid Referral Form
EPSDT Provider Agreement
EPSDT Provider Enrollment Form
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