Forms

General Program

• Eligibility Criteria (Effective 07/01/2024)
• Income Eligibility Guidelines (Effective 02/01/2024)
• Reimbursement Rate Table (Effective 02/01/2024)
• Reimbursement Rate Table, Color Coded (Effective 02/01/2024)
• Med-It Website Enrollment Instructions
• Health Department ABCCEDP Clinical Protocol
• Provider Manual
• Regional Coordinator Contact List
• Regional Coordinator Map

Medicaid Treatment Program

• Treatment Referral Form

Contractual

• Provider Contract Under $15,000
• Provider Contract $15,000 & Over
• Contract Document Checklist
• Disclosure Statement
• Certificate of Compliance
• E-Verify Information
• STAARS Vendor Self Service Information
• Important Vendor Information Regarding Alabama Buys
• ABCCEDP Provider Checklist
• ABCCEDP Sub-Contractor Form

Data and Billing

• Mammography Voucher
• Screening Form
• Cervical Diagnostic Follow-Up Form
• Breast Diagnostic Follow-Up Form
• Informed Consent Form | Formulario de Autorización
• Health Insurance Claim Form
• Breast MRI Authorization Form