Alabama Form 369 – Fill Out and Use This PDF

Alabama Form 369 is an application for a business license. It must be completed by the owner of the company, not someone else.

If you are checking how to get this form, you've clicked the right link. Our PDF tool is a convenient software that may help you get the necessary document in no time. Use any suitable device - desktop, phone, tablet, or laptop.

Get Form Now Download PDF

Alabama Form 369 first page preview

Alabama Form 369 PDF Details

Alabama Form 369 is an income tax form used by Alabama taxpayers to report their state income tax liability. The form is three pages long, and consists of sections for your name, address, and other identifying information; your federal adjusted gross income (AGI); your Alabama taxable income; and your state taxes owed. There are also lines for subtracting any credits you may be eligible for, and for calculating your total payment amount. The form must be filed by April 15th each year. If you're filing a Form 369 for the first time, or if you need help completing it, the Alabama Department of Revenue has a number of resources available on their website.

Below is the information regarding the file you were in search of to complete. It can show you the time you will require to finish alabama form 369, what parts you will have to fill in and a few additional specific details.

Question	Answer
Form Name	Alabama Form 369
Form Length	2 pages
Fillable?	Yes
Fillable fields	138
Avg. time to fill out	28 min 10 sec
Other names	alabama medicaid pa form, OTC, corticosteroid, alabama medicaid prior authorization form

12

Form Preview Example

Street or PO Box /City/State/Zip

Page 1

Alabama Medicaid Pharmacy

Prior Authorization Request Form

rPage 1 of 1 r Page 1 of 2

FAX: (800) 748-0116

Fax or Mail to

P.O. Box 3210

Phone: (800) 748-0130

Health Information Designs

Auburn, AL 36823-3210

PATIENT INFORMATION

Patient name

Patient Medicaid #

Patient DOB

Patient phone # with area code

Nursing home resident r Yes

PRESCRIBER INFORMATION

Prescriber name

NPI #

License #

Phone # with area code

Fax # with area code

Address (Optional)

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*

Strength

J Code

Qty.

Days supply

PA Refills: 0 1

2 3 4 5 Other

If applicable

Diagnosis or ICD-9/ICD-10 Code

Diagnosis or ICD-9/ICD-10 Code

r Initial Request

r Renewal

r

Maintenance Therapy

r Acute Therapy

Medical justification

r Additional medical justification attached.

Medications received through coupons and samples are not acceptable as justification.

*If the drug being requested is a brand name drug with an exact generic equivalent available, the FDA MedWatch Form 3500 must be submitted to HID in addition to the PA Request Form.



		DRUG SPECIFIC INFORMATION

r ADD/ADHD Agents	r Alzheimer’s Agent		r Androgens	r Antidepressants		r Antidiabetic Agent
r Antiemetic Agents	r Antihistamine		r Antihyperlipidemics	r Antihypertensives		r Antipsychotic Agents
r Antiinfective	r Anxiolytics, Sedatives and Hypnotics			r Cardiac Agents		r EENT-Antiallergics
r EENT-Vasoconstrictors	r Estrogens		r H2 Antagonist	r Intranasal Corticosteroids		r Narcotic Analgesics
r NSAID	r Oral Anticoagulants		r Platelet Aggregation Inhibitors			r PPI
r Respiratory Agents	r Skeletal Muscle Relaxants		r Skin & Mucous Membrane Agent r Triptans			r Other

List previous drug usage and length of treatment as defined in instructions for drug class requested.

Generic/Brand/OTC

Reason for d/c

Therapy start date

Therapy end date

Generic/Brand/OTC

Reason for d/c

Therapy start date

Therapy end date

If no previous drug usage, additional medical justification must be provided.

DISPENSING PHARMACY INFORMATION

May Be Completed by Pharmacy

Dispensing pharmacy

NPI #

Phone # with area code

Fax # with area code

NDC #

NOTE: See Instruction sheet for specific PA requirements on the Medicaid website at www.medicaid.alabama.gov

Alabama Medicaid Agency

Form 369

Revised 7/1/15

www.medicaid.alabama.gov

Page 2

Patient Medicaid #

rSustained Release Oral Opioid Agonist

Proposed duration of therapy						Is medicine for PRN use?			r Yes	r No
Type of pain r Acute r Chronic						Severity of pain: r Mild			r Moderate r Severe
Is there a history of substance abuse or addiction? r Yes				r No
If yes, is treatment plan attached?			r Yes r No
Indicate prior and/or current analgesic therapy and alternative management choices
Drug/therapy					Reason for d/c
Drug/therapy					Reason for d/c

r Antipsychotic Agents			The request is for:	r Monotherapy or r Polytherapy

For children < 6 years of age, have monitoring protocols (see Attachment C on the Alabama Medicaid website) been followed? r Yes r No For polytherapy and/or off-label use, please provide medical justification to support the use of the drug being requested.

Medical justification may include peer reviewed literature, medical record documentation, chart notes with specific symptoms that the support the diagnosis, etc.

rXenicalR

r

If initial request

Weight

kg.

Height

inches

BMI

kg/m2

r

If renewal request

Previous weight

kg.

Current weight

kg.

Documentation MD supervised exercise/diet regimen > 6 mo.? r Yes

r No

Planned adjunctive therapy? r Yes

r No

r Phosphodiesterase Inhibitors
Failure or inadequate response to the following alternate therapies:
1.				2.			3.
4.				5.			6.
Contraindication of alternate therapies:
r Documentation of vasoreactivity test attached					r Consultation with specialist attached

r Specialized Nutritionals			Height		inches	Current weight			kg.

rIf < 21 years of age, record supports that > 50% of need is met by specialized nutrition

rIf > 21 years of age, record supports 100% of need is met by specialized nutrition

Method of administration		Duration						# of refills

r Xolair®	Current Weight:__________kg (patient’s weight must be between 30-150kg)
Is the patient 12 years or older?				r	Yes	r	No
Is the request for chronic idiopathic urticaria?				r	Yes	r	No
Is the request for moderate to severe asthma and is treatment recommended by a board
certified pulmonologist or allergist after their evaluation (if yes answers questions below)?				r	Yes	r	No
Has the patient had a positive skin or blood test reaction to a perennial aeroallergen?				r	Yes	r	No
Is the patient symptomatic despite receiving a combination of either inhaled corticosteroid
and a leukotriene inhibitor or an inhaled corticosteroid and long acting beta agonist or has
the patient required 3 or more bursts of oral steroids within the past 12 months?				r	Yes	r	No
Are the patient’s baseline IgE levels between 30 IU/mL and 700 IU/mL?				r	Yes	r	No
Level:_________________	Date:__________________

Form 369	Alabama Medicaid Agency
Revised 7-1-15	www.medicaid.alabama.gov

How to Edit Alabama Form 369 Online for Free

Our PDF editor allows you to complete forms. It's not necessary to perform much to change rheumatologist files. Simply check out the next actions.

Step 1: Choose the button "Get Form Here".

Step 2: The form editing page is now open. You can include text or manage present data.

The PDF file you wish to complete will contain the following areas:

part 1 to completing corticosteroid

Put the necessary data in the CLINICAL, INFORMATION Drug, requested Strength, Q, ty Days, supply PA, Refills, Other J, Code If, applicable Diagnosis, or, ICD, ICD, Code Diagnosis, or, ICD, ICD, Code r, Initial, Request, Medical, justification r, Renewal r, Maintenance, Therapy, r, Acute, Therapy DRUG, SPECIFIC, INFORMATION and Therapy, start, date, Therapy, start, date box.

stage 2 to filling out corticosteroid

It is vital to provide certain particulars within the box Dispensing, pharmacy Phone, with, area, code DISPENSING, PHARMACY, INFORMATION MayBe, Completed, by, Pharmacy NP, I and Fax, with, area, code

Entering details in corticosteroid part 3

You have to describe the rights and obligations of each side in space Reason, for, dc, Reason, for, dc Patient, Medicaid inches, BMI kg, m and Current, weight

Finishing corticosteroid part 4

Fill in the form by analyzing these fields: Current, weight Planned, adjunct, ive, therapy, rYe, s, rNo rP, hos, ph, odi, est, erase, Inhibitors r, Consultation, with, specialist, attached Method, of, administration of, refills rYe, sr, Yes and rN, or, No

stage 5 to finishing corticosteroid

Step 3: Once you click on the Done button, the finalized file is conveniently transferable to any type of of your devices. Or, you may send it via mail.

Step 4: Be sure to stay clear of possible future troubles by preparing at least a couple of duplicates of your document.

Watch Alabama Form 369 Video Instruction

Alabama Form 369 isn’t the one you’re looking for?

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .