Home
News
About Medicaid
Alabama Medicaid Pharmacy Study Commission
ALERTS
Boards & Committees
Calendar
News Articles
Publications
Procurement
Presentations
Regional Care Organizations
Statistics
Topics & Issues
Apply
General Information
Qualifying for Medicaid
Applications & Forms
Contacts & Locations
LTC Partnership Program
Apply Online
Expedite Online Nursing Home Application System
Programs
Care Networks
Covered Services
Long Term Care Services
Medical Services
Pharmacy Services / DME
Quality Initiatives
Health Information Technology
Transportation
Other Programs
Patient 1st
APEC - Perinatal Collaborative
Resources
A – Z Index
Administrative Code
Help/Search
Forms Library
Online Catalog
Site Map
State Plan
Links
Other State Medicaid Programs
Providers
Benefit Coordination/Third Party
Checkwrite Schedules
Vendor Companion Guides
Frequently Asked Questions
ICD-10
Fee Schedules
Manuals
News & Notices
Prior Authorization
Provider Electronic Solutions Software
Provider Enrollment
Release of Information
CAQH CORE Operating Rules
Secure Web Portal - Logon
Fraud
What is Fraud & Abuse?
Medicaid Program Integrity Division
Consumer Protection & Privacy
Preventing Fraud - Recipients
Preventing Fraud - Providers
Reporting Fraud and Abuse
Suspended Providers
Recovery Audit Contractor Audits
PERM Provider Education Sessions
Contact
Medicaid Contacts
HP Contact Information
Contact Information for Applicants
Electronic Media Claims Helpdesk
Provider Assistance Center
Provider Enrollment
Recipients
My Medicaid
Apply Online
Applicant/Recipient Forms
Change Patient 1st Doctor
Educational Documents
Helpful Links
Privacy
Spanish-Language Documents
Advance Directives
Update Health Insurance Info
Frequently Asked Questions
Reference
Medicaid Staff login
About Medicaid
Administrative Code
Checkwrite schedule
Covered Services/Co-pays
Manuals
State Plan
Forms for Recipients

 
Forms Number and Descriptions
Apply Online Use Online form for SOBRA, MLIF or Plan First
Joint Application NEW! Apply for coverage that starts on or after January 1, 2014
Appendix A if someone in the household is eligible for health coverage from a job
Appendix B if applicant or family member is an American Indian or Alaska Native
Appendix C Form to use if applicant wishes to give a trusted person permission to help with the application (authorized representative)
Medicaid Applications  
Form 204/205  
fillable
Application for Elderly and Disabled programs
Addresses to mail application - Updated 8/27/14
Tips for Applying Know what information you need to have when applying for elderly and disabled assistance  
Form 284 To enroll children of Medicaid-eligible mothers (including SSI mothers) from birth to first birthday
   
Eligibility Forms  
Form 202 To appoint someone as a Medicaid recipient's representative
Form 262 Qualifying Income Trust Packet- For a Medicaid applicant who is entering a nursing home and has excess income
Form 295 Instructions For Recipient Change Form 
Form 295 Recipient Change Form to tell Medicaid about changes to a recipient's status (move, income, marital status, etc.) - Fillable
Form 211 - fillable Medicare Savings Program Form for help paying Medicare premiums.
Form 211
Information
Addresses to mail application - Updated 8/27/14
Get more information
about the Medicare Savings Program
Form 357  
   
Third Party Benefit Coordination Forms  
Form 333 Health Insurance Premium Payment Application - Fillable
Form 3P-1 Request Release of recipient's information - Fillable
Form 3P-2 To report changes in insurance coverage - Fillable
   
Patient 1st Forms  
Form 354 Request for Newborn Assignment - Fax or Mail
Form 393 Grievance Form - to tell Medicaid if you have a complaint about a Patient 1st provider
Form 349  To change your personal doctor - fillable - Mail
Form 349 To change your personal doctor - fillable - Fax