Ala. Admin. Code r. 560-X-28-.01 - Forms

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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Ala. Admin. Code r. 560-X-28-.01
Rule effective October 1, 1982. Amended effective January 8, 1986; December 18, 1986; April 14, 1987; July 10, 1987; September 9, 1987; February 9, 1988; May 10, 1988. Emergency rule effective June 17, 1988; October 7, 1988. Amended effective October 12, 1988; January 10, 1989; April 17, 1990; July 13, 1991; March 13, 1992; November 12, 1992; January 13, 1993. Amended: Filed April 6, 1994; effective May 11, 1994. Amended: Filed July 7, 1994; effective August 12, 1994. Amended: Filed May 11, 2012; effective June 15, 2012. Adopted by Alabama Administrative Monthly Volume XXXVI, Issue No. 09, June 29, 2018, eff. July 26, 2018.

Authors: Stephanie Lindsay, Administrator, Administrative Procedures Officer

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

Notes

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