Get Al Phy-81243 2016

Filling out the AL PHY-81243 form is a crucial step for individuals undergoing a hysterectomy under Alabama Medicaid. This guide provides clear instructions on how to complete the form accurately to ensure its acceptance.

Follow the steps to complete the AL PHY-81243 form online.

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. In Part I, begin by entering the name of the patient and their 13-digit Medicaid number. Provide a detailed description of the diagnosis requiring the hysterectomy, along with the corresponding diagnosis code. If applicable, include the name of a representative who will sign the form on behalf of the patient.
3. Continue with Part I by entering the name and NPI number of the physician performing the hysterectomy. Make sure the physician signs and dates this section prior to the surgery date.
4. In Part II, enter the patient's name and date of birth. If a representative is completing the form, include their name as well. The patient must sign and date this section, ensuring the date corresponds to the surgery or an earlier date.
5. If a representative is signing, they must also provide their signature and date in Part II, adhering to the same date requirements as noted before.
6. Part III requires the date of surgery to be entered once the procedure has been completed.
7. In Part IV, if the hysterectomy was performed due to unusual circumstances, input the patient's name and 13-digit Medicaid number. Indicate the specific unusual circumstance by checking the appropriate box, and confirm whether the patient was informed about the implications of the surgery.
8. The physician must sign and date Part IV, ensuring the date aligns with the surgery or an earlier date.
9. Lastly, complete Part V by having the reviewer at the State sign and note the reason for any denial, along with the date of review.
10. Once all sections are completed, save your changes, and consider downloading, printing, or sharing the form as needed.

Complete your AL PHY-81243 form online to ensure a smooth submission process.