Alabama Administrative Code
Title 560 - ALABAMA MEDICAID AGENCY
Chapter 560-X-28 - FORMS USED BY AGENCY
Section 560-X-28-.01 - Forms

Universal Citation: AL Admin Code R 560-X-28-.01

Current through Register Vol. 43, No. 02, November 27, 2024

The following forms are presented as reference and to illustrate examples of official forms referred to within the rules contained in the Alabama Medicaid Agency Administrative Code. Copies of all official forms utilized by the Alabama Medicaid Agency may be obtained free-of-charge on the Agency's website at www.medicaid.alabama.gov. [File Link Not Available]

(1) Alabama Medicaid Agency Plastic Identification Card.

(2) Alabama Medicaid Agency Referral Form-Alabama Medicaid Agency Form 362 (rev. 02/23/2012).

(3) Alabama Medicaid Agency Certification and Documentation for Abortion-Alabama Medicaid Agency Form PHY-92-2 (rev. 09/29/2016).

(4) Alabama Medicaid Agency Hysterectomy Consent Form-Alabama Medicaid Agency Form PHY-81243 (rev.09/29/2016).

(5) Alabama Medicaid Agency Sterilization Consent Form-Alabama Medicaid Agency Form 193 (rev. 09/29/2016).

(6) Assurance of Compliance-Form HHS-690 (rev. 01/10/2017).

(7) Health Insurance Benefit Agreement-Form CMS-1561 (rev. 07/2001).

(8) Health Insurance Claim Form-CMS-1500 (rev. 02/2012).

(9) Appointment of Representative-Alabama Medicaid Agency Form 202 (rev. 07/2014).

(10) Petition for Declaratory Ruling-Alabama Medicaid Agency Form 901 (rev. 11/01/2017).

(11) Petition for Rule Change-Alabama Medicaid Agency Form 902 (rev. 11/01/2017).

(12) Medicaid Patient Status Notification-Alabama Medicaid Agency Form 199 (formerly Form XIX-LTC-4) (rev. 02/13/2008).

(13) Nursing Facility/Resident Agreement-Alabama Medicaid Agency Form 154 (formerly Form XIX-LTC-10) (rev. 01/2015).

(14) Admission and Evaluation Data-Alabama Medicaid Agency Form 161 (formerly Form XIX-LTC-9) (rev. 03/25/2015).

(15) Lien for Medical Payments under Alabama Medicaid Agency-Alabama Medicaid Agency Form 220 (rev. 01/20/1995).

(16) Home Health Certification and Plan of Care-Form CMS-485 (C-3) (formerly HCFA-485) (rev. 12/2014).

(17) Uniform Bill-CMS-1450 (UB-04) (formerly UB-82 and UB-92) (rev. 02/2012).

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Authors: Stephanie Lindsay, Administrator, Administrative Procedures Officer

Statutory Authority: Code of Ala. 1975, § 41-22-4; Alabama Medicaid Agency Administrative Code.

Disclaimer: These regulations may not be the most recent version. Alabama may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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