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

Current through Register Vol. 42, No. 9, June 28, 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.