Please rate Alabama Medicaid Referral 6-2023
Today's Date: enter the date the form is completed. Referral Date: enter the date the referral becomes effective.
Length of referral: must be completed for the referral to be valid.
Case Management/Care Coordination: referral for case management services through Network Care Coordinators.
Lock-In: referral for recipients on lock-in status who are locked in to one doctor and/or one pharmacy.
EPSDT: referral resulting from an EPSDT screening; indicate screening date.
Other: all other referral types.
| Question | Answer |
|---|---|
| Form Name | Form 362 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 45 |
| Avg. time to fill out | 8 min |
| Edition | Rev 6/2023 |
| Issuing agency | Alabama Medicaid Agency |
| Other names | 362, Form 362, Medicaid referral form, Alabama Medicaid referral form, Alabama Medicaid Referral Form |
| Official source | Form 362 (Rev 6/2023), Alabama Medicaid Agency |
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Please rate Alabama Medicaid Referral 6-2023
