Alabama Form 390 – Fill Out and Use This PDF

Alabama Form 390 is the prior authorization request form used by prescribers and dispensing pharmacies to request approval for miscellaneous pharmacy items through the Alabama Medicaid program. The form captures patient details, prescriber and pharmacy information, the drug requested, diagnosis codes, and medical justification for the treatment. For compounding prescriptions, it also requires ingredient details and time units. To fill out Alabama Form 390, click the button below to open the PDF editor.

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Alabama Form 390 PDF Details

Alabama Form 390 is a prior authorization document used by Medicaid enrollees who require medications or treatments not automatically covered under the Alabama Medicaid program. Prescribers and pharmacies submit it to demonstrate that the requested treatment meets Alabama Medicaid Agency guidelines before the medication is dispensed.

The form is sent to Health Information Designs via fax or mail. Key information required on the form includes:

Patient name, Medicaid ID number, and date of birth

Prescriber name, NPI number, and state license number

Dispensing pharmacy name, phone, fax, and NPI

Drug name, NDC code, strength, quantity, and number of days or weeks requested

ICD-9 or ICD-10 diagnosis codes that justify the medication

Medical justification for the treatment, referencing clinical guidelines or prior treatment failures

EPSDT notation for eligible Medicaid recipients under age 21

For compounding prescriptions, the form requires the compounding ingredients, quantities, and time units requested. The prescribing practitioner must certify that the treatment is medically necessary and follows all Alabama Medicaid guidelines.

Related forms that may be required alongside Form 390 include the Alabama Medicaid Referral form and the Pharmacy Prior Authorization form. Healthcare providers who work with multiple payer types may also need to complete an Aetna Pharmacy Prior Authorization form for patients with private insurance.

Question	Answer
Form Name	Alabama Form 390
Also Known As	Alabama Medicaid PA form, Alabama Medicaid prior authorization form
Form Length	1 page
Who Submits It	Prescribers and dispensing pharmacies
Submitted To	Health Information Designs (HID)
Submission Method	Fax or mail
Purpose	Prior authorization for miscellaneous pharmacy items under Alabama Medicaid

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
❒	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*
◆ 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

How to Edit Alabama Form 390 Online for Free

How to Fill Out Alabama Form 390 Step by Step

Follow these steps to complete the form correctly and avoid delays in the approval process:

Enter patient information. Write the patient's full name, Medicaid ID number, and date of birth in the fields at the top of the form.
Add prescriber details. Include the prescriber's full name, NPI number, state license number, and contact phone number.
Fill in pharmacy information. Enter the dispensing pharmacy name, phone number, fax number, and NPI.
Specify the drug requested. Enter the drug name, NDC code, strength, and quantity. Include the number of days, weeks, or months of treatment being requested.
Provide diagnosis codes. List the ICD-9 or ICD-10 diagnosis codes that support the medication request.
Write the medical justification. Explain why the requested drug is medically necessary. Reference relevant clinical guidelines or prior treatment attempts with alternative medications where available.
Complete the EPSDT section. If the request involves Early and Periodic Screening, Diagnostic, and Treatment services for a Medicaid recipient under age 21, check the appropriate box.
Sign and date the form. The prescribing practitioner must sign and date the certification to confirm the accuracy of the information.
Submit the completed form. Fax or mail the form to Health Information Designs at the address or fax number listed on the form.

Common Mistakes to Avoid

Healthcare providers frequently encounter delays due to these errors on Alabama Form 390:

Leaving the NPI blank for either the prescriber or the dispensing pharmacy
Using outdated ICD-9 codes where ICD-10 codes are now required
Omitting the medical justification or writing a generic reason that does not reference the patient's specific clinical situation
Failing to check the EPSDT box for eligible patients under age 21
Submitting the form without the prescriber's signature and date

Frequently Asked Questions About Alabama Form 390

Who submits Alabama Form 390?

The form is submitted by the prescribing physician or the dispensing pharmacy on behalf of the patient. Either party can initiate the prior authorization request with Alabama Medicaid.

Where do you send Alabama Form 390?

Completed forms are sent to Health Information Designs (HID), which manages prior authorization requests for the Alabama Medicaid program. The fax number and mailing address are printed on the form.

How long does prior authorization take?

Alabama Medicaid typically processes non-urgent prior authorization requests within 3 business days. Urgent medical requests may be processed within 24 hours.

What happens if the request is denied?

If the prior authorization is denied, the prescriber receives a written notice explaining the reason. The prescriber can appeal by submitting additional clinical documentation to support the request. Patients may also request a fair hearing through the Alabama Medicaid Agency.

Can Form 390 be used for all medications?

No. Form 390 covers miscellaneous pharmacy requests only. Other medications may require a different prior authorization form. Check the Alabama Medicaid pharmacy guidelines to confirm which form applies to the specific drug. For mental health medications, providers may also need to complete an antipsychotic prior authorization form depending on the drug category.