The Alabama 390 form is a crucial document used to request prior authorization for certain medications under the Alabama Medicaid program. This form ensures that patients receive necessary treatments while adhering to established guidelines set by the Alabama Medicaid Agency. Understanding how to properly complete and submit this form can significantly impact patient care and access to medications.
The Alabama 390 form serves as a crucial document for healthcare providers seeking prior authorization for certain pharmacy services under the Alabama Medicaid program. This form facilitates the submission of requests for medications that may not be covered without prior approval, ensuring that patients receive necessary treatments in a timely manner. It requires detailed patient information, including the patient's name, Medicaid number, date of birth, and contact details. The prescriber must also provide their name, National Provider Identifier (NPI), and other relevant credentials to confirm their authority in overseeing the patient's treatment. Furthermore, the form includes sections dedicated to the dispensing pharmacy, drug requested, and clinical information, which must be thoroughly completed to support the request. Specifics such as drug quantity, compounding details, and medical justifications are essential components of the form. The Alabama Medicaid Agency reviews these submissions to determine eligibility and appropriateness, thus ensuring that patients receive the medications they need while adhering to established guidelines.
Alabama Medicaid Pharmacy
Miscellaneous PA Request Form
FAX: (800) 748-0116
Fax or Mail to
P.O. Box 3210
Phone: (800) 748-0130
Health Information Designs
Auburn, AL 36832-3210
PATIENT INFORMATION
Patient name
Patient Medicaid #
Patient DOB
Patient phone # with area code
Nursing home resident ❒ Yes
PRESCRIBER INFORMATION
Prescriber name
NPI #
License #
Phone # with area code
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 Phone # with area code NDC #
Fax # with area code Drug Requested
DRUG/CLINICAL INFORMATION
Required for all requests
❒
Drug request – Complete this section
Quantity per month
Compounding Professional Fee – Complete items marked ◆ and next section
PA Refills:
0 1 2 3 4 5 Other
◆ Diagnosis
ICD-9
Code*
◆ ❒ Initial Request
◆
❒ Renewal
◆Medical justification
◆ ❒ Additional medical justification attached.
❒ EPSDT Referral form attached
*See Instruction Sheet, Section 4
COMPOUNDING SPECIFIC INFORMATION
Compounding Ingredients (Ing.)
Ing. Name
If more ingredients are required, attach additional sheets.
Compounding Time
Units Requested (in minutes)
FOR HID USE ONLY
❒ Approve request
❒ Deny request
❒ Modify request
❒ Medicaid eligibility verified
Comments
Reviewer’s Signature
Response Date/Hour
FORM 390
Alabama Medicaid Agency
Revised 2/23/08
www.medicaid.alabama.gov
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