Alabama Form 450 is an important document for taxpayers in the state. It is used to report your income and calculate your taxes. The form can be filed online or by mail, and must be submitted by April 15th each year. There are a number of instructions and worksheets that accompany the form, so it's important to make sure you understand them all before filing. If you need help filling out Alabama Form 450, you can contact the IRS or seek assistance from a tax professional. Filing your taxes on time is important, so make sure you start working on Alabama Form 450 as soon as possible!
Question | Answer |
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Form Name | Alabama Form 450 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | enrollee, recipients, Medicaid, ALABAMA |
Patient 1st Recipient Dismissal Form
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Recipient Name _________________________________________________ DOB ___________________
Medicaid Number _____________________________________ Gender Male Female
Address __________________________________________________ Telephone # __________________
City __________________________________________________ State ________ Zip _____________
Name ____________________________________________ NPI # ________________________________
Reason for Dismissal
Recipient Behavior Non Compliance w/treatment Other _____________________________
To assist you and the recipient in the dismissal process, please list the name and telephone number of any referral for this recipient within the last 30 days or send copy of the referral.
Referred To
Diagnosis
Date
Length of Referral
After care management, would you accept this recipient back in your practice? Yes No
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For Medicaid Office Use Only |
Refer to Care Coordinator |
Refer to |
A Primary Medical Provider may request removal of a recipient from his panel due to good cause.* All requests for patients to be removed from a PMP’s panel should be submitted on this form and provide the enrollee 30 days written notice. The request should contain documentation as to why the PMP does not wish to serve as the recipient’s PMP.
*IAW: ALABAMA MEDICAID BILLING MANUAL CHAPTER 39
Please send form to Patient 1st Fax at (334)
FORM 450 |
www.medicaid.alabama.gov |
Revised 10/13/2011 |
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