Alabama Medicaid Agency
Elderly and Disabled Programs
Instructions: Read this application carefully and follow all instructions given throughout the form.
Answer each question completely and accurately.
You may have someone help you complete the application. If you have questions about this application, email: Apply@medicaid.alabama.gov.
1. *Send verification of the gross (before taxes) amount of your monthly income.
2. *Send a copy of your Social Security card.
3. *If you have Medicare, send a copy of your Medicare card.
4. Type your full name in the applicant's signature field.
5. Click “Submit” at the end of the application to submit electronically.
*You may upload these documents in the attachments section before the last page of this application.
Anyone who makes, or causes to be made, a false statement, misrepresentation
or omission of a material fact in an application, or for use in determining eligibility for Medicaid,
commits a crime punishable under federal or state law, or both.
Notice to Applicants and Sponsors
Federal and state laws provide both criminal and civil penalties for false statements or material
omissions in an application for Medicaid benefits or payments. Also, any application found to contain
material misstatements or omissions will be denied.
The following statutes are excerpts from the Code of Alabama pertaining to the Medicaid program:
S 22-1-11. Making false statement or representation of material fact in claim or application for
payments on medical benefits from Medicaid agency generally; kickbacks, bribes,
etc.; exceptions; multiple offenses.
(a) Any person who, with intent to defraud or deceive, makes, or causes to be made or assists
in the preparation of any false statement representation or omission of a material fact in any claim
or application for any payment, regardless of amount, from the Medicaid agency, knowing the
same to be false; or with intent to defraud or deceive, makes, or causes to be made, or assists in
the preparation of any false statement, representation or omission of a material fact in any claim or
application for medical benefit from the Medicaid agency, knowing the same to be false; shall be
guilty of a felony and upon conviction thereof shall be fined not more than $10,000.00 or
imprisoned for not less than one nor more than five years, or both.
* * *
(e) Any two or more offenses in violation of this section may be charged in the same
indictment in separate counts for each offense and such offense shall be tried together, with
separate sentences being imposed for each offense of which defendant is found guilty. (Acts
1980, No. 80-539, p. 837, Sections 1-5.)
S 22-6-8, Revocation of eligibility of recipient upon determination of abuse, fraud, or misuse of
benefits; when eligibility may be restored.
(a) Upon determination by a utilization review committee of the designated state Medicaid
agency that a Medicaid recipient has abused, defrauded, or misused the benefits of the program
said recipient shall immediately become ineligible for Medicaid benefits.
(b) Medicaid recipients whose eligibility has been revoked due to abuse, fraud or other
deliberate misuse of the program shall not be deemed eligible for future Medicaid services for a
period of not less than one year and until full restitution has been made to the designated state
(c) The provisions of this section shall not be effective if they are found by a court of
competent jurisdiction to contravene federal laws or federal regulations applicable to the
(Acts 1980, No. 80-127, p.190.)
Medicaid Eligibility Policies and Procedures are in compliance with
Civil Rights Act of 1964,
Section 504 of the Rehabilitation Act of 1973, Federal Age Discrimination Act
of 1975 and the Americans with Disabilities Act of 1990.