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Get AL Form 409 2008-2024

This form can be filled out while viewing in Adobe Acrobat Reader. Then print it and fax or mail to HID Alabama Medicaid Pharmacy Override Request Form FAX 800 748-0116 Phone 800 748-0130 Fax or Mail to HEALTH INFORMATION DESIGNS P. O. Box 3210 Auburn AL 36832-3210 PATIENT INFORMATION Patient name Patient Medicaid Patient DOB Nursing home resident Yes Patient phone with area code PRESCRIBER INFORMATION NPI Prescriber name Phone with area code License Fax with area code Address Optional 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 DISPENSING PHARMACY INFORMATION Dispensing pharmacy NDC J Code Qty. requested per month CLINICAL INFORMATION Early Refill Maximum Unit/Maximum Cost Therapeutic Duplication Brand Limit Switch Over Requested drug name Strength Date of request Medication lost Physician changed the dosage Patient going out of town for period greater than the day s supply remaining of the previous refill* Documentation Supporting Documentation Attached For Maximum Unit or Maximum Cost Diagnosis Medical Justification For Therapeutic Duplication or Brand Limit Switch Over Reason for Request Strength/Dosage change Switch over Titration and Concomitant Therapy Drug name Qty. Stop date if applicable Reason for change Stop date is required for strength/dosage change or switch over. Attach medical justification if both drugs are to be continued titration/concomitant therapy. For specific documentation requirement see Override instructions on the Medicaid web site. FOR HID USE ONLY Approve request Deny request Modify request Medicaid eligibility verified Comments Reviewer s Signature Form 409 Revised 2/23/08 Response Date/Hour www. O. Box 3210 Auburn AL 36832-3210 PATIENT INFORMATION Patient name Patient Medicaid Patient DOB Nursing home resident Yes Patient phone with area code PRESCRIBER INFORMATION NPI Prescriber name Phone with area code License Fax with area code Address Optional 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. I will be supervising the patient s treatment. Supporting documentation is available in the patient record. Prescribing Practitioner Signature Date DISPENSING PHARMACY INFORMATION Dispensing pharmacy NDC J Code Qty. Prescribing Practitioner Signature Date DISPENSING PHARMACY INFORMATION Dispensing pharmacy NDC J Code Qty. requested per month CLINICAL INFORMATION Early Refill Maximum Unit/Maximum Cost Therapeutic Duplication Brand Limit Switch Over Requested drug name Strength Date of request Medication lost Physician changed the dosage Patient going out of town for period greater than the day s supply remaining of the previous refill* Documentation Supporting Documentation Attached For Maximum Unit or Maximum Cost Diagnosis Medical Justification For Therapeutic Duplication or Brand Limit Switch Over Reason for Request Strength/Dosage change Switch over Titration and Concomitant Therapy Drug name Qty. .

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