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  • Al Form 369 2019

Get Al Form 369 2019-2025

Alabama Medicaid Pharmacy Prior Authorization Request Form Page 1 FAX 800 748-0116 Phone 800 748-0130 r Page 1 of 1 Fax or Mail to Health Information Designs P. O. Box 3210 Auburn AL 36823-3210 PATIENT INFORMATION Patient name Patient DOB Patient Medicaid Patient phone with area code Nursing home resident r Yes PRESCRIBER INFORMATION Prescriber name NPI Phone with area code Address Optional License Fax with area code Street or PO Box /City/State/Zip I certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by the Alabama Medicaid Agency. I will be supervising the patient s treatment. Supporting documentation is available in the patient record. Prescribing Practitioner Signature Date CLINICAL INFORMATION Drug requested J Code If applicable Qty. Initial Request Strength Days supply Diagnosis or ICD-9 Code r PA Refills 0 1 2 3 4 5 Other Renewal Maintenance Therapy r Acute Therapy Medical justification r Additional medical justification attached*....

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232