Long-Term Care Forms

Note: Hospice, Nursing Home, PEC, Swing-Bed and Inpatient Psychiatric records must be electronically uploaded.  For more information on this requirement, click here
Facility Forms
Form 154 Nursing Home Agreement for Care - Updated 1/27/15
Form 161 LTC Admission and Evaluation Data Form - Effective 5/1/15
Admission Criteria LTC Admission Criteria Based on Administrative Code Rule 560-X-10-10
Form 161 - I LTC and Evaluation Data Form Instructions - Effective 5/1/15
Form 161 Example Example of Form 161 instructions that goes along with Form 161 Instructions - Effective 5/1/15
Form 161-B Long Term Care Request for Action
Form 199 Patient Status Notification
Form 361 Used to evaluate the Level of Care Evaluation needed when entering an ICF/IID institutional care facility
Form 362 For use in applying for HCBS Waiver -- ICF/IID Level of Care Evaluation for Institutional Care
Form 376 Waiver and PACE Slot Confirmation
Form 402 Request Administrative Review of Outdated Medicaid Claim
Form 431 MDS Section Q Nursing Home Discharge Planning Checklist
Form  12-001 Admission and Evaluation Assessment Tool for PACE Program
TB Checklist HCBS Waiver TB Screening Checklist
Order Forms Interagency Transfer Form - Click here to order CM-1 Targeted Case Management Forms
Estate Recovery Forms
Estate Administrator Form Fillable form to designate a beneficiary of patient trust funds - Return to Alabama Medicaid Agency/Estate Recovery Unit
Instructions - Estate
Administrator Form
Estate Administration Designation Form Instructions
   
Gateway to Community Living Forms
Referral Form For requesting information about Medicaid services available to assist in returning to community living
Transition Plan Form Individual Transition Plan Form - For Case Managers
Informed Consent Informed Consent with Options Counseling Form - For Case Managers
Assessment Tool Return to Community Assessment Tool- For Case Managers
Private Duty Nursing Forms
Form 387 PDN Verification of Employment or School Attendance
Form 388 PDN Agreement for Care

 

Hospice Forms
Form 165 Hospice Election -  Fillable
Form 165 Instructions Instructions for Hospice Election Form - Effective 9/1/13
Form 165-A Hospice Cover Sheet -  Fillable
Form 165-B Hospice Recipient Status Change - Fillable
Form 435 Hospice Provider (Nursing Facility Rate Request Form) - Fillable