Alabama Administrative Code Chapter 560-X-28 — Forms Used by Agency

560 Alabama Medicaid Agency

Ala. Admin. Code r. 560-X-28-.01 Forms

The following forms are presented as reference and to illustrate examples of official forms referred to within the rules contained in the Alabama Medicaid Agency Administrative Code. Copies of all official forms utilized by the Alabama Medicaid Agency may be obtained free-of-charge on the Agency’s website at www.medicaid.alabama.gov.

(1) Alabama Medicaid Agency Plastic Identification Card.

(2) Alabama Medicaid Agency Referral Form—Alabama Medicaid Agency Form 362 (rev. 02/23/2012).

(3) Alabama Medicaid Agency Certification and Documentation for Abortion—Alabama Medicaid Agency Form PHY-92-2 (rev. 09/29/2016).

(4) Alabama Medicaid Agency Hysterectomy Consent Form—Alabama Medicaid Agency Form PHY-81243 (rev.09/29/2016).

(5) Alabama Medicaid Agency Sterilization Consent Form—Alabama Medicaid Agency Form 193 (rev. 09/29/2016).

(6) Assurance of Compliance—Form HHS-690 (rev. 01/10/2017).

(7) Health Insurance Benefit Agreement—Form CMS-1561 (rev. 07/2001).

(8) Health Insurance Claim Form—CMS-1500 (rev. 02/2012).

(9) Appointment of Representative—Alabama Medicaid Agency Form 202 (rev. 07/2014).

(10) Petition for Declaratory Ruling—Alabama Medicaid Agency Form 901 (rev. 11/01/2017).

(11) Petition for Rule Change—Alabama Medicaid Agency Form 902 (rev. 11/01/2017).

(12) Medicaid Patient Status Notification—Alabama Medicaid Agency Form 199 (formerly Form XIX-LTC-4) (rev. 02/13/2008).

(13) Nursing Facility/Resident Agreement—Alabama Medicaid Agency Form 154 (formerly Form XIX-LTC-10) (rev. 01/2015).

(14) Admission and Evaluation Data—Alabama Medicaid Agency Form 161 (formerly Form XIX-LTC-9) (rev. 03/25/2015).

(15) Lien for Medical Payments under Alabama Medicaid Agency—Alabama Medicaid Agency Form 220 (rev. 01/20/1995).

(16) Home Health Certification and Plan of Care—Form CMS-485 (C-3) (formerly HCFA-485) (rev. 12/2014).

(17) Uniform Bill—CMS-1450 (UB-04) (formerly UB-82 and UB-92) (rev. 02/2012).

History

• Author: Stephanie Lindsay, Administrator, Administrative Procedures Officer
• Authority: Code of Ala. 1975, §41-22-4; Alabama Medicaid Agency Administrative Code.
• Rule effective October 1, 1982. Amended effective January 8, 1986; December 18, 1986; April 14, 1987; July 10, 1987; September 9, 1987; February 9, 1988; May 10, 1988. Emergency rule effective June 17, 1988; October 7, 1988. Amended effective October 12, 1988; January 10, 1989; April 17, 1990; July 13, 1991; March 13, 1992; November 12, 1992; January 13, 1993. Amended: Filed April 6, 1994; effective May 11, 1994. Amended: Filed July 7, 1994; effective August 12, 1994. Amended: Filed May 11, 2012; effective June 15, 2012. Repealed and New Rule (Text and Forms): Filed June 11, 2018; effective July 26, 2018.

Ala. Admin. Code r. 560-X-28-.02 Summary Of State Law Regarding Advanced Directives

(1) Deciding about your health care.

(b) If you are 19 or older, the law says you have the right to decide about your medical care.

(c) If you are very sick or badly hurt, you may not be able to say what medical care you want.

(d) If you have an advance directive, your doctor and family will know what medical care you want if you are too sick or hurt to talk or make decisions.

(2) What is an advance directive?

(a) An advance directive is used to tell your doctor and family what kind of medical care you want if you are too sick or hurt to talk or make decisions. If you do not have one, certain members of your family will have to decide on your care.

(b) You must be at least 19 years old to set up an advance directive. You must be able to think clearly and make decisions for yourself when you set it up. You do not need a lawyer to set one up, but you may want to talk with a lawyer before you take this important step. Whether or not you have an advance directive, you have the same right to get the care you need.

(3) Types of advance directives.

(a) In Alabama you can set up an Advance Directive for Health Care. The choices you have include:

(b) A living will is used to write down ahead of time what kind of care you do or do not want if you are too sick to speak for yourself.

(c) A proxy can be part of a living will. You can pick a proxy to speak for you and make the choices you would make if you could. If you pick a proxy, you should talk to that person ahead of time. Be sure that your proxy knows how you feel about different kinds of medical treatments.

(d) Another way to pick a proxy is to sign a durable power of attorney for health care. The person you pick does not need to be a lawyer.

(e) You can choose to have any or all of these three advance directives: Living will, proxy and/or durable power of attorney for health care.

(f) Hospitals, home health agencies, hospices and nursing homes usually have forms you can fill out if you want to set up a living will, pick a proxy or set up a durable power of attorney for health care. If you have questions, you should ask your own lawyer or call the Department of Senior Services for help.

(4) When you set up an advance directive.

(a) Be sure and sign your name and write the date on any form or paper you fill out. Talk to your family and doctor now so they will know and understand your choices. Give them a copy of what you have signed. If you go to the hospital, give a copy of your advance directive to the person who admits you to the hospital.

(5) What do I need to decide?

(a) You will need to decide if you want treatments or machines that will make you live longer even if you will never get better. An example of this is a machine that breathes for you.

(b) Some people do not want machines or treatments if they cannot get better. They may want food and water through a tube or pain medicine. With an advance directive, you decide what medical care you want.

(6) Talk to your doctor and family now.

(a) The law says doctors, hospitals and nursing homes must do what you want or send you to another place that will. Before you set up an advance directive, talk to your doctor ahead of time. Find out if your doctor is willing to go along with your wishes. If your doctor does not feel he or she can carry out your wishes, you can ask to go to another doctor, hospital or nursing home.

(b) Once you decide on the care you want or do not want, talk to your family. Explain why you want the care you have decided on. Find out if they are willing to let your wishes be carried out.

(c) Family members do not always want to go along with an advance directive. This often happens when family members do not know about a patient’s wishes ahead of time or if they are not sure about what has been decided. Talking with your family ahead of time can prevent this problem.

(7) You can change your mind any time.

(a) As long as you can speak for yourself, you can change your mind any time about what you have written down. If you make changes, tear up your old papers and give copies of any new forms or changes to everyone who needs to know.

(8) For help or more information:

(a) Alabama Department of Senior Services 1-800-243-5463

For Alabama law and sample advance directive form:

The “Natural Death Act” of Alabama, Chapter 8A of Title 22 of the Code of Ala. 1975.

History

• Author: Stephanie Lindsey, Administrator, Administrative Procedures Officer
• Authority: State Plan §§4.13(e), Code of Ala. 1975, §41-22-1 et seq.; Alabama Medicaid Agency Administrative Code; 42 U.S.C. §§1396a(a)(58), 1396a(w).
• New Rule: Filed June 8, 1999; effective July 13, 1999. Amended: Filed June 11, 2018; effective July 26, 2018.