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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How to fill out the AL Form 369 online
Filling out the AL Form 369 online can streamline the prior authorization process for Alabama Medicaid pharmacy services. This guide provides clear instructions to help users accurately complete each section of the form.
Follow the steps to complete the AL Form 369 online.
- Press the ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling out the patient information section. Enter the patient's name, Medicaid number, date of birth, and phone number with area code. Indicate if the patient is a nursing home resident by selecting 'Yes' or 'No'.
- Next, fill in the prescriber information. Include the prescriber's name, National Provider Identifier (NPI) number, phone number with area code, and optional address. Enter the license number and fax number with area code.
- Sign and date the prescriber’s certification to confirm that the treatment is necessary and meets Alabama Medicaid guidelines.
- Move to the clinical information section. Specify the drug requested, its J Code if applicable, and provide strength, quantity, and days supply. Indicate the diagnosis with either ICD-10 Code or select options for initial requests, renewal, or maintenance therapy.
- Document the medical justification by selecting if additional justification is attached and noting that medications received through coupons or samples are not acceptable as justification.
- Complete the drug-specific information by selecting the relevant drug category and providing details on previous drug usage and treatment history, including reasons for discontinuation and therapy start and end dates.
- Fill out the dispensing pharmacy information, including pharmacy name, phone number, NPI number, fax number, and National Drug Code (NDC).
- If applicable, add any additional details related to sustained release opioids, pain severity, history of substance abuse, and prior analgesic therapy, including documentation if necessary.
- Finally, review the completed form for accuracy. Users can then save their changes, download, print, or share the form as needed.
Complete your documents online today for a hassle-free submission process.
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