Get Al Medicaid Referral Form

Filling out the Al Medicaid Referral Form online can simplify the process of assigning your newborn to a physician. This guide will walk you through each section of the form, ensuring you provide accurate information for a smooth experience.

Follow the steps to complete your online form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the mother's name in the designated field. Make sure to provide her full name accurately, as it is essential for the Medicaid assignment process.
3. In the following field, enter the mother's Medicaid number. This number is crucial for identifying the mother's eligibility for Medicaid services.
4. Next, provide the name of the physician who will be assigned to the newborn. Fill in the first, middle initial, and last name as required.
5. If known, include the physician or clinic's Medicaid provider number in the specified field to facilitate the assignment.
6. Enter the physician's address to ensure that communications regarding the newborn's care can be properly directed.
7. Fill in the unborn/Medicaid number of the baby, which is needed for administrative purposes and to link the newborn to Medicaid.
8. Input the baby’s name as well as their address, including city and zip code, to register their information correctly.
9. Provide a phone number for the baby, including the area code. This contact information may assist in any follow-up communications.
10. Acknowledge that you have the right to choose a Patient 1st doctor. This affirmation is made by signing in the signature field as the parent or guardian.
11. Enter the date of signing as required to validate the form.
12. Under the 'Name of Person Completing Form' section, provide your name and contact information, including phone and fax numbers.
13. Once all fields are completed, ensure to review the form for any errors or missing information.
14. To submit the form, save your changes, download, print, and then you may fax it to 334-215-4140 or mail it to Hewlett Packard, 301 Technacenter Drive, Montgomery, AL 36117.

Complete your Al Medicaid Referral Form online today for a seamless experience.