For hard copy referrals, the printed, typed, or stamped name of the screening provider with an original signature of the provider or designee is required.
Hard copy signatures: stamped or copied signatures will not be accepted.
Electronic referrals: provider certification is made via standardized electronic signature protocol.
Length of referral: indicate the number of visits or length of time for which the referral is valid; it must be completed for the referral to be valid.
Evaluation and treatment: the consultant can evaluate and treat for diagnosis listed on the referral.
Consultant: the consultant can be an individual provider or provider group.
| Question | Answer |
|---|---|
| Form Name | Form 362 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 45 |
| Avg. time to fill out | 8 min |
| Edition | 6/2023 |
| Issuing agency | Alabama Medicaid Agency |
| Other names | Form 362, 362 form, Alabama Form 362, Alabama Medicaid Form 362, Medicaid Referral Form, Alabama Medicaid Referral Form |
| Official source | Form 362 (Rev 6/2023), Alabama Medicaid Agency |
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