Please complete the form below by adding the required doctor and paitent information, then fax to our office. The form has been pre-filled with our information for your convenience.
EPSDT Referral Form Required by Medicaid (Ages 5-20 only).
Telehealth services available for all Alabama Medicaid clients 15-20 years of age
Can only be a referral from a Medicaid PCP Approved Provider
(Psychiatrists and PMHNPs cannot refer)
