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Alabama Medicaid Form 161: LTC Admission & Evaluation

Alabama nursing facilities complete Form 161 for every Medicaid admission, readmission, transfer between approved Medicaid facilities and spend-down admission. It records admission dates, diagnoses, medications and the Rule 560-X-10-10 criteria the resident meets. A physician, nurse practitioner or physician assistant then certifies that the resident requires nursing facility care effective on the Medicaid admission date shown on the form.

Who completes it

Facility staff enter admission and identifying data, and the registered nurse who assesses level of care completes the diagnosis, medication and criteria sections and signs. A physician, NP or PA signs the certification; the NP or PA cannot be employed by the facility.

Submitting and payment

How to submit it
The form is typed or completed in ink and kept in the facility's files. It must be complete, including the RN signature and the certification, before the facility enters the Medicaid admission date in the long-term care notification software used to bill Medicaid.

Good to know

  • List the criteria met as letters a to k and, for criterion k, the specific numbers 1 to 9. The facility record must validate those criteria for the Medicaid admission date.
  • When criteria G or K-9 are used, the diagnosis section must document an unstable medical condition requiring active treatment in the 60 days before admission.
  • The RN attaches all pertinent diagnoses and a list of every medication the resident receives for the Medicaid admission month, with route, dosage, time, treatments and diet.
  • Alabama Medicaid posts the admission criteria sheet, Form 161-I line-by-line instructions and a numbered example beside the form, which is dated 03-25-15.

Get the official form

Download the current version from the source each time; forms change without notice.

LTC Admission and Evaluation Data Form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can sign the certification on Alabama Medicaid Form 161?

A physician, nurse practitioner or physician assistant certifies that the resident requires nursing facility care effective on the admission date on the form, attesting that the certification date is the Medicaid admission date. An NP or PA who signs cannot be employed by the facility. The facility's RN reviewer signs separately.

What is the Medicaid admission date on Form 161?

Per the Form 161-I instructions, it is the date the recipient meets both Medicaid medical and financial eligibility for the current admission. The Medicare admission date is recorded only if Medicare Part A covered the stay just before; otherwise the facility writes NA and gives the reason no Medicare days were used.

When is a new Form 161 needed?

For each new admission, readmission, transfer from one approved Medicaid facility to another, and spend-down admission. When a resident is later discharged or dies, the facility records that date on the Form 161 whose admission date matches the stay being closed.