Alabama Form 390 PDF Details

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!

QuestionAnswer
Form NameAlabama Form 390
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesNDC, DOB, alabama medicaid pa form, Reviewers

Form Preview Example

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 #

NPI #

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*

 

 

 

 

 

 

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

 

Ing. Name

 

Ing. Name

 

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