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Form 377 Patient-Centered Medical Home (Pcmh) Recognition Attestation Form - Alabama, 2024 PDF

Form 377 Patient-Centered Medical Home (Pcmh) Recognition Attestation Form - Alabama, 2024
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Patient-Centered Medical Home (Pcmh) Recognition Attestation Form - Alabama, 2022 PDF

Patient-Centered Medical Home (Pcmh) Recognition Attestation Form - Alabama, 2022
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Form 202 Appointment of Representative - Alabama PDF

Form 202 Appointment of Representative - Alabama
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Form WAV-37 Attachment A Tb Baseline Screening Assessment - Alabama PDF

Form WAV-37 Attachment A Tb Baseline Screening Assessment - Alabama
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Form 342 Alabama Prior Review and Authorization Request - Alabama PDF

Form 342 Alabama Prior Review and Authorization Request - Alabama
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Form 361 Icf/Iid Level of Care Evaluation for Institutional Care - Alabama PDF

Form 361 Icf/Iid Level of Care Evaluation for Institutional Care - Alabama
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Form 362 Icf/Iid Level of Care Evaluation - Alabama PDF

Form 362 Icf/Iid Level of Care Evaluation - Alabama
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Form 384 Wheelchair/Seating Evaluation - Alabama PDF

Form 384 Wheelchair/Seating Evaluation - Alabama
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Form 386 Wheelchair Modification/Repair Form - Alabama PDF

Form 386 Wheelchair Modification/Repair Form - Alabama
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Form W-9 Taxpayer Identification Number Request - Alabama PDF

Form W-9 Taxpayer Identification Number Request - Alabama
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Alabama Gateway to Community Living Individual/Sponsor Statement of Understanding - Alabama PDF

Alabama Gateway to Community Living Individual/Sponsor Statement of Understanding - Alabama
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Gateway to Community Living Referral Form - Alabama PDF

Gateway to Community Living Referral Form - Alabama
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Alabama Medicaid Dossier Submission Form - Alabama PDF

Alabama Medicaid Dossier Submission Form - Alabama
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Form 165 Medicaid Hospice Election and Physician's Certification - Alabama PDF

Form 165 Medicaid Hospice Election and Physician's Certification - Alabama
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Form 193 Alabama Medicaid Agency Sterilization Consent Form - Alabama PDF

Form 193 Alabama Medicaid Agency Sterilization Consent Form - Alabama
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Form 295 Alabama Medicaid Agency's Recipient Change Report Form - Alabama PDF

Form 295 Alabama Medicaid Agency's Recipient Change Report Form - Alabama
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Form 140 Family Planning Assessment Record - Alabama PDF

Form 140 Family Planning Assessment Record - Alabama
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Form 343 Alabama Prior Review and Authorization Dental Request - Alabama PDF

Form 343 Alabama Prior Review and Authorization Dental Request - Alabama
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Form 404 Request for Administrative Review of Outdated Medicaid Claim - Alabama PDF

Form 404 Request for Administrative Review of Outdated Medicaid Claim - Alabama
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Form PHY-81243 Hysterectomy Consent Form - Alabama PDF

Form PHY-81243 Hysterectomy Consent Form - Alabama
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Alabama Medicaid Telemedicine Recipient Consent Form - Alabama PDF

Alabama Medicaid Telemedicine Recipient Consent Form - Alabama
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Form 175 Family Planning Home Visit - Alabama PDF

Form 175 Family Planning Home Visit - Alabama
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Form MED PHE91-30-1 Biographical Data Sheet Consent Form - Alabama PDF

Form MED PHE91-30-1 Biographical Data Sheet Consent Form - Alabama
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Form 138 Family Planning Services Consent Form - Alabama PDF

Form 138 Family Planning Services Consent Form - Alabama
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Form 154 Nursing Facility/Resident Agreement - Alabama PDF

Form 154 Nursing Facility/Resident Agreement - Alabama
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Form PHY-96-2 Certification and Documentation for Abortion - Alabama PDF

Form PHY-96-2 Certification and Documentation for Abortion - Alabama
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Form 392 Patient Consent Form - Hepatitis C Agents - Alabama PDF

Form 392 Patient Consent Form - Hepatitis C Agents - Alabama
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Form 371 Certification of Need for Services: Emergency Admission to a Psychiatric Residential Treatment Facility - Alabama PDF

Form 371 Certification of Need for Services: Emergency Admission to a Psychiatric Residential Treatment Facility - Alabama
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Residential Treatment Facility Model Attestation Letter - Alabama PDF

Residential Treatment Facility Model Attestation Letter - Alabama
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Psychologist Supervisor Contract Termination - Alabama PDF

Psychologist Supervisor Contract Termination - Alabama
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Psychologist Supervision Contract Change of Address Form - Alabama PDF

Psychologist Supervision Contract Change of Address Form - Alabama
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Form 370 Certification of Need for Services: Non-emergency Admission to a Psychiatric Residential Treatment Facility - Alabama PDF

Form 370 Certification of Need for Services: Non-emergency Admission to a Psychiatric Residential Treatment Facility - Alabama
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Supervision Contract - Alabama PDF

Supervision Contract - Alabama
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Diagnostic Intake Interview - Alabama PDF

Diagnostic Intake Interview - Alabama
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Behavior Assessment and Treatment Request for Applied Behavioral Analysis for Autism Spectrum Disorder - Alabama PDF

Behavior Assessment and Treatment Request for Applied Behavioral Analysis for Autism Spectrum Disorder - Alabama
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Form 172 Epsdt Child Health Medical Record - Alabama PDF

Form 172 Epsdt Child Health Medical Record - Alabama
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Form 284 Newborn Certification - Alabama PDF

Form 284 Newborn Certification - Alabama
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Form 391 Pcp Override Request Form - Alabama PDF

Form 391 Pcp Override Request Form - Alabama
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Instructions for Form 193 Alabama Medicaid Agency Sterilization Consent Form - Alabama PDF

Instructions for Form 193 Alabama Medicaid Agency Sterilization Consent Form - Alabama
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Form 362 Alabama Medicaid Referral Form - Alabama PDF

Form 362 Alabama Medicaid Referral Form - Alabama
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