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Appendix E Medicaid Forms

Appendix E Medicaid Forms

 

INSTRUCTIONS: ALABAMA MEDICAID FORMS (Appendix E)

 

 

This article discusses a packet of supplemental forms that may need to be filed if covered by Alabama Medicaid. This packet can be obtained from the website maintained by the Alabama Medicaid Agency.

 

Alabama Medicaid Forms Appendix E Step 1: The first page contains a table listing the documents contained within the packet.

 

Alabama Medicaid Forms Appendix E Step 2: The second page contains form E.1, which is a certification and documentation for abortion.

 

Alabama Medicaid Forms Appendix E Step 3: The third page contains form E.2, which is a check refund form.

 

Alabama Medicaid Forms Appendix E Step 4: The fourth page contains form E.3, which is an Alabama prior review and authorization dental request.

 

Alabama Medicaid Forms Appendix E Step 5: The fifth page contains form E.4, which is a hysterectomy consent form, while the sixth page contains instructions for completion.

 

Alabama Medicaid Forms Appendix E Step 6: The sixth and seventh pages contain form E.5, which is a patient status notification form.

 

Alabama Medicaid Forms Appendix E Step 7: The eight page contains form E.6, which is an Alabama prior review and authorization review form.

 

Alabama Medicaid Forms Appendix E Step 9: The ninth page contains form E.7, which is a sterilization consent form.

 

Alabama Medicaid Forms Appendix E Step 10: The tenth page contains form E.8, which is a family planning services consent form.

 

Alabama Medicaid Forms Appendix E Step 11: The eleventh page contains form E.9, which is a prior authorization request form.

 

Alabama Medicaid Forms Appendix E Step 12: The twelfth page contains form E.10, which is an early refill DUR override request form.

 

Alabama Medicaid Forms Appendix E Step 13: The thirteenth page contains form E.11, which is a growth hormone for AIDS wasting form.

 

Alabama Medicaid Forms Appendix E Step 14: The fourteenth page contains form E.12, which is a growth hormone for children request form.

 

Alabama Medicaid Forms Appendix E Step 15: The fifteenth page contains form E.13, which is an adult growth hormone request form.

 

Alabama Medicaid Forms Appendix E Step 16: The sixteenth page contains form E. 14, which is a Maximum Unit Override form.

 

Alabama Medicaid Forms Appendix E Step 17: The remainder of the package contains forms E.15 through E.29.

 

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