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.

QuestionAnswer
Form NameAlabama Form 369
Form Length2 pages
Fillable?Yes
Fillable fields138
Avg. time to fill out28 min 10 sec
Other namesalabama medicaid pa form, OTC, corticosteroid, alabama medicaid prior authorization form

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

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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 CLINICALINFORMATION, Drugrequested, Strength, Qty, Dayssupply, PARefillsOther, JCode, Ifapplicable, DiagnosisorICDICDCode, DiagnosisorICDICDCode, rInitialRequestMedicaljustification, rRenewal, rMaintenanceTherapyrAcuteTherapy, DRUGSPECIFICINFORMATION, and TherapystartdateTherapystartdate box.

stage 2 to filling out corticosteroid

It is vital to provide certain particulars within the box Dispensingpharmacy, Phonewithareacode, DISPENSINGPHARMACYINFORMATION, MayBeCompletedbyPharmacy, NPI, and Faxwithareacode.

Entering details in corticosteroid part 3

You have to describe the rights and obligations of each side in space ReasonfordcReasonfordc, PatientMedicaid, inchesBMI, kgm, and Currentweight.

Finishing corticosteroid part 4

Fill in the form by analyzing these fields: Currentweight, PlannedadjunctivetherapyrYesrNo, rPhosphodiesteraseInhibitors, rConsultationwithspecialistattached, Methodofadministration, ofrefills, rYesrYes, and rNorNo.

stage 5 to finishing corticosteroid

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