Get Medicaid Alabama Form

NEWBORN CERTIFICATION FORM Alabama Medicaid Agency Provider s Name Attn Family Certification Division Address P. O. Box 5624 Montgomery Alabama 36130-5624 Telephone Telephone Number 334 242-1744 Fax Number 334 242-0566 Fax Instructions Please provide identifying information. Medicaid will provide eligibility and medicaid number. If mother s ssn is not known please provide an address in the comment section* MOTHER S NAME SSN COUNTY INFANT S NAME D. O. B. SEX ELIGIBILITY MEDICAID NUMBER Provider s Comments Medicaid s Comments I certify that medical service supplies and/or equipment were provided to the infant s named above. Signature of Provider s Representative Date Signature of Medicaid s Representative Please note Information given is to assist with filing claims and is not intended to be used as authorization for payment. Should a claim be denied the explanation listed on the Provider Explanation of Payment will be Medicaid s reason for denial* Form 265 Revised 8/14/00. If mother s ssn is not known please provide an address in the comment section* MOTHER S NAME SSN COUNTY INFANT S NAME D. O. B. SEX ELIGIBILITY MEDICAID NUMBER Provider s Comments Medicaid s Comments I certify that medical service supplies and/or equipment were provided to the infant s named above. O. B. SEX ELIGIBILITY MEDICAID NUMBER Provider s Comments Medicaid s Comments I certify that medical service supplies and/or equipment were provided to the infant s named above. Signature of Provider s Representative Date Signature of Medicaid s Representative Please note Information given is to assist with filing claims and is not intended to be used as authorization for payment. Signature of Provider s Representative Date Signature of Medicaid s Representative Please note Information given is to assist with filing claims and is not intended to be used as authorization for payment. Should a claim be denied the explanation listed on the Provider Explanation of Payment will be Medicaid s reason for denial* Form 265 Revised 8/14/00. If mother s ssn is not known please provide an address in the comment section* MOTHER S NAME SSN COUNTY INFANT S NAME D. O. B. SEX ELIGIBILITY MEDICAID NUMBER Provider s Comments Medicaid s Comments I certify that medical service supplies and/or equipment were provided to the infant s named above. Signature of Provider s Representative Date Signature of Medicaid s Representative Please note Information given is to assist with filing claims and is not intended to be used as authorization for payment. O. B. SEX ELIGIBILITY MEDICAID NUMBER Provider s Comments Medicaid s Comments I certify that medical service supplies and/or equipment were provided to the infant s named above. Signature of Provider s Representative Date Signature of Medicaid s Representative Please note Information given is to assist with filing claims and is not intended to be used as authorization for payment. Should a claim be denied the explanation listed on the Provider Explanation of Payment will be Medicaid s reason for denial* Form 265 Revised 8/14/00.