Alabama Request For Medical Records
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1This form may be filled in on the computer. Print and fax to Health Management Systems (HMS) at FAX (866) 274-5974.
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Information filled in on the computer will NOT be saved when the document is closed. Print a copy before closing.
Alabama Medicaid Agency
Request for Medical Records
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All fields must be completed to expedite requests
Records Requested By Attorney
Recipient Insurance Company
Provider
Name/Firm
Address
Phone
FAX
Claim # (if applicable)
I am requesting medical records from the following medical providers:
(Medicaid will notify the requestor of any Medicaid subrogation/assignment interest. Medicaid will sign and return the
form to you. Please present it to medical providers when requesting medical records.)
Medicaid Recipient Information
Name
Date of birth
SSN or Medicaid Number
Reason for Request of Medical Records
Date of injury / Onset of medical problem
Initial complaint
Type of accident / injury
I am requesting Medicaid payment information / copies of claims paid by Medicaid.
Under HIPAA regulations, this request must be accompanied by a signed authorization releasing this information to you.
I am forwarding a request for medical records received from an attorney / insurance company or other entity.
Direct requests for medical records relating to tort actions to:
Health Management Systems
Attention: AL Case Management Unit
2000 Interstate Park Dr., Suite 401
Montgomery, AL 36109
Toll Free Telephone: 1-877-252-8949
For Completion by Third Party Division/HMS
Medicaid acknowledges receipt of the Request for Medical Records related to the above-stated date of
injury/medical care. (Any released records must have stamped or written in a prominent place the following
statement: MEDICAID HAS SUBROGATION/ASSIGNMENT RIGHTS)
_____________________________________________
____________________________
Zeffie Smith or LaTonya Jackson
Date
Revised 4-29-2015
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Parent category: Medical