Follow the steps to complete your AL Form 369 accurately

1. Press the ‘Get Form’ button to access the form, allowing you to open it in your preferred editor.
2. Begin by filling in the patient information section. Enter the patient’s full name, Medicaid number, date of birth, and contact number with area code. If applicable, indicate if the patient is a resident of a nursing home by selecting ‘Yes’.
3. Next, complete the prescriber information section. Provide the prescriber’s name, NPI number, contact number with area code, and, optionally, their address and license number.
4. In the clinical information section, specify the requested drug's name, J Code (if applicable), strength, quantity, and days' supply. Fill in the appropriate diagnosis or ICD-10 code. Select whether this is an initial request or a renewal and specify the number of refills needed.
5. Detail the medical justification for the request, ensuring to attach any additional medical justification if necessary. Remember that medications obtained through coupons or samples are not valid for justification.
6. Complete the drug-specific information by selecting the relevant drug class and listing previous drug usage, including reasons for discontinuation, start, and end dates for therapy.
7. If applicable, fill out the dispensing pharmacy information, including pharmacy name, contact number with area code, NPI number, fax number, and NDC number.
8. Finally, review all the provided information for accuracy. Once completed, you can save your changes, download the form, print it, or share it as needed.

Complete your AL Form 369 online today to ensure efficient processing of your prior authorization requests.