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Alabama Medicaid Form 362: EPSDT Referral Form

Alabama Medicaid's Form 362 documents a referral to another provider after an EPSDT screening, for case management or care coordination, or for a recipient on lock-in status. The screening provider sets what the consultant may do, from evaluation only to evaluation and treatment or cascading referrals, and how long the referral lasts. The consultant then sends written findings back to the screening provider.

Who completes it

The screening provider must complete and sign the form when an EPSDT screening leads to a referral, entering their NPI and Medicaid provider ID. The consultant, an individual provider or group, returns a written report with the exam date, diagnosis and signature.

Submitting and payment

How to submit it
The referring office gives the form to the consultant and keeps it in the record; the screening provider marks whether findings should come back by mail, email or fax, and whether to telephone as well.

Good to know

  • On paper, the screening provider's printed, typed or stamped name needs an original signature by the provider or designee; stamped or copied signatures are not accepted.
  • For electronic referrals, check the electronic signature verification box to confirm the electronic signature is valid. The fillable version dated May 2025 includes that box.
  • The Length of Referral field, in visits or months, must be completed or the referral is not valid.
  • Mark periodic for well-child checkups on the periodicity schedule, or interperiodic for problem-focused screenings of undiagnosed conditions outside that schedule.

Get the official form

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

Alabama Medicaid Referral Form

Official pagePDF

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

Can a consultant refer onward on Alabama Medicaid Form 362?

Yes, if the screening provider allows it. A cascading referral lets the consultant send the recipient to another specialist for the condition on the form without a new referral. For EPSDT only, the consultant may also refer for additional conditions they diagnose.

Can Alabama Medicaid Form 362 be signed electronically?

Yes. For electronic referrals, provider certification is made through a standardized electronic signature protocol, and the electronic signature checkbox must be selected. Paper referrals need an original signature from the screening provider or designee next to the printed, typed or stamped name.

What referral types does Form 362 cover besides EPSDT?

Case management or care coordination through Network Care Coordinators, lock-in referrals for recipients locked in to one doctor or one pharmacy, and other referral types the provider describes. The Alabama Medicaid Provider Manual gives claim filing instructions for EPSDT and lock-in referrals.