Get Al Form 369 2019-2025

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.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. 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'.
3. 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.
4. Sign and date the prescriber’s certification to confirm that the treatment is necessary and meets Alabama Medicaid guidelines.
5. 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.
6. 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.
7. 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.
8. Fill out the dispensing pharmacy information, including pharmacy name, phone number, NPI number, fax number, and National Drug Code (NDC).
9. 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.
10. 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.