Wheelchair Modification/Repair Form ***This form is mandatory for prior authorizations

Medicaid Agency

This government document is issued by Medicaid Agency for use in Alabama

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File Details: PDF (595 KB)
Downloads: 16
Source
https://medicaid.alabama.gov/documents/9.0_Resources/9.4_Forms_Library/9.4.14_PA_Forms/9.4.14_PA_Form_386_Wheelchair_Modification_Revised_10-11-17.pdf

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