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.

INSTRUCTIONS: ARIZONA WITHDRAWAL OR TERMINATION REQUEST FOR CHILD CARE PROVIDERS (Form CCA-1170A)

Arizona child care providers who wish to have their certification terminated or application for certification withdrawn should complete a form CCA-1170A. This document can be obtained from the website maintained by the Arizona Department of Economic Security. Note that this form is provided as a text document. You are required to complete this document by typing your answers on a word processor. Note that you may also submit this request verbally. If so, this document will be completed by the official you speak with. 

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 1: In the first box, enter your last name, first name and middle initial.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 2: in the second box, enter your phone number, including the area code.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 3: Check Section A if you wish to withdraw your request for a fair hearing.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 4: Check Section B if you wish to withdraw your request to become a DES certified family care provider. Note that checking this box will result in either the closure or denial of your application.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 5: Check Section C if you wish to terminate your DES child care certification. Note that this may result in the revocation of your certification. You must either attach your DES certificate or surrender it within seven days of termination. Indicate with a check mark which course of action you are taking.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 6: Check Section D if you wish to terminate your NCRP registration agreement.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 7: In the section where indicated, write your reason for withdrawing your request or wishing to terminate your certification.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 8: In the blank box below this section, enter your signature.

Arizona Withdrawal Or Termination Request For Child Care Providers CCA-1170A Step 9: In the blank box to the right of this, enter the date.