The Alabama Form 390 is an important document for business owners and individuals in the state. This form is used to report taxable income, and it must be filed with the Alabama Department of Revenue. There are a number of requirements that must be met in order to file the Alabama Form 390, so it is important to understand these before you submit your return. In this blog post, we will provide an overview of the Alabama Form 390 and discuss some of the things you need to know in order to complete it correctly. We hope this information will help you make sense of this complex form and ensure that your tax return is filed accurately. Stay tuned for more tips on preparing your taxes in Alabama!
Question | Answer |
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Form Name | Alabama Form 390 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | NDC, DOB, alabama medicaid pa form, Reviewers |
Alabama Medicaid Pharmacy
Miscellaneous PA Request Form
FAX: (800) |
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Fax or Mail to |
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P.O. Box 3210 |
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Phone: (800) |
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Health Information Designs |
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Auburn, AL |
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PATIENT INFORMATION |
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Patient name |
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Patient Medicaid # |
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Patient DOB |
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Patient phone # with area code |
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Nursing home resident ❒ Yes |
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PRESCRIBER INFORMATION |
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Prescriber name |
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NPI # |
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License # |
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Phone # with area code |
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Fax # with area code |
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Address (Optional) |
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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 |
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DISPENSING PHARMACY INFORMATION
Dispensing pharmacy Phone # with area code NDC #
NPI #
Fax # with area code Drug Requested
DRUG/CLINICAL INFORMATION
Required for all requests
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Drug request – Complete this section |
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Quantity per month |
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Compounding Professional Fee – Complete items marked ◆ and next section |
PA Refills: |
0 1 2 3 4 5 Other |
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◆ Diagnosis |
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Code* |
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◆ Diagnosis |
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Code* |
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◆ ❒ Initial Request |
◆ |
❒ Renewal |
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◆Medical justification
◆ ❒ Additional medical justification attached. |
❒ EPSDT Referral form attached |
*See Instruction Sheet, Section 4 |
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COMPOUNDING SPECIFIC INFORMATION
Compounding Ingredients (Ing.) |
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Ing. Name |
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Ing. Name |
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Ing. Name |
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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 |
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Comments |
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Reviewer’s Signature |
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Response Date/Hour |
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FORM 390 |
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Alabama Medicaid Agency |
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Revised 2/23/08 |
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www.medicaid.alabama.gov |