Claims

Judgment of Sentence/Commitment to Jail

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Authorization to Disclose Health Information

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Alabama Department of Agriculture And Industries Internship Application

  INSTRUCTIONS: ALABAMA DEPARTMENT OF AGRICULTURE AND INDUSTRIES INTERNSHIP APPLICATION     To apply for an internship with the Alabama Department of Agriculture and Industries, use the document discussed in
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Form 10_2011 MedImpact Prescription Drug Claim Form

  INSTRUCTIONS: ALABAMA PRESCRIPTION DRUG CLAIM FORM (Form 10_2011)     To process claims for prescription drugs for Alabama public employees enrolled in coverage administered by Medimpact, use the claim
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Motion/Order of Nolle Prosequi

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Claim Kit for self-insured trust members

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WC Claim Summary Form WC 4

  INSTRUCTIONS: ALABAMA CLAIMS SUMMARY FORM (Form WC 4)   When an Alabama employee is injured on the job, their
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Form CL-438 Medical Expense Claim

  INSTRUCTIONS: ALABAMA MEDICAL EXPENSE CLAIM (Form CL-438)     Alabama public employees enrolled in a program administered by BlueCross
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Order Committing Juvenile to Family Independence Agency

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Doctor’s Report of Treatment

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