Alabama Form 409 PDF Details

Alabama Form 409 is an important document to have if you are a business owner in the state of Alabama. This document outlines the various taxes that your business may be liable for, and it can help you to stay compliant with state tax laws. If you are unsure about what taxes your business may be responsible for, or if you need help filing your Alabama Form 409, make sure to consult with a professional accountant or tax specialist. By doing so, you can ensure that your business is in compliance with all applicable tax laws, and you can avoid any potential penalties or fines.

QuestionAnswer
Form NameAlabama Form 409
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names2020 alabama withholding form, state withholding form alabama, medicaid pharmacy override, request alabama pharmacy

Form Preview Example

This form can be filled out while viewing in Adobe Acrobat Reader. Then print it and fax or mail to HID

Alabama Medicaid Pharmacy

Override 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

 

 

 

 

 

License #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

NPI #

 

 

 

 

NDC #

 

 

 

 

 

 

 

 

J Code

 

 

 

 

 

 

Qty. requested per month

 

 

Phone # with area code

 

 

 

 

 

 

Fax # with area code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLINICAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Early Refill

Maximum Unit/Maximum Cost

Therapeutic Duplication

Brand Limit Switch Over

Requested drug name

 

 

 

 

 

Strength

 

 

Date of request

 

 

 

For Early Refill

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication lost

 

 

Physician changed the dosage

 

 

 

 

 

Medication destroyed

 

Medication stolen

 

 

 

 

Patient going out of town for period greater than the day’s supply remaining of the previous refill.

Documentation

Supporting Documentation Attached

For Maximum Unit or Maximum Cost

Diagnosis

Medical Justification

For Therapeutic Duplication or Brand Limit Switch Over

 

Diagnosis

 

Reason for Request

Strength/Dosage change*

Switch over

 

 

Titration and Concomitant Therapy**

Drug name

 

NDC

 

 

 

Qty.

 

 

Stop date

 

 

 

 

 

 

 

 

 

 

 

 

if applicable

Drug name

 

NDC

 

 

 

Qty.

 

 

Stop date

 

 

 

 

 

 

 

 

 

 

 

 

if applicable

Reason for change

 

 

 

 

 

 

 

 

 

 

 

* Stop date is required for strength/dosage change or switch over.

 

 

 

 

Medical justification attached

**Attach medical justification if both drugs are to be continued (titration/concomitant therapy). For specific documentation requirement, see Override instructions on the Medicaid web site.

FOR HID USE ONLY

Approve request

Deny request

Modify request

Medicaid eligibility verified

Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reviewer’s Signature

 

 

 

Response Date/Hour

Form 409

 

 

 

Alabama Medicaid Agency

Revised 2/23/08

 

 

 

www.medicaid.alabama.gov

How to Edit Alabama Form 409 Online for Free

Dealing with PDF documents online is always super easy with our PDF editor. Anyone can fill out request alabama pharmacy here effortlessly. Our editor is constantly evolving to grant the very best user experience attainable, and that is thanks to our dedication to constant enhancement and listening closely to customer comments. Getting underway is simple! Everything you need to do is take the following basic steps down below:

Step 1: Just click on the "Get Form Button" at the top of this site to start up our pdf form editing tool. Here you will find all that is required to work with your document.

Step 2: The tool offers the capability to work with PDF forms in a range of ways. Change it with your own text, correct what's originally in the file, and include a signature - all when you need it!

Pay attention while completing this form. Make certain all required blanks are done correctly.

1. You need to complete the request alabama pharmacy properly, hence be careful when filling out the segments that contain all of these fields:

Ways to complete alabama medicaid override form step 1

2. The next stage is usually to submit these particular fields: Requested drug name For Early, Strength, Date of request, Medication lost Medication, Physician changed the dosage , Documentation, Supporting Documentation Attached, For Maximum Unit or Maximum Cost, Diagnosis, Medical Justification, For Therapeutic Duplication or, Diagnosis, Switch over, Titration and Concomitant Therapy, and Drug name.

How one can fill in alabama medicaid override form portion 2

Be very careful while filling in Titration and Concomitant Therapy and Switch over, because this is where most users make some mistakes.

3. The next part is going to be hassle-free - fill out all of the form fields in Approve request, Deny request, Modify request, Medicaid eligibility verified, Comments, Reviewers Signature, Form Revised , Response DateHour, and Alabama Medicaid Agency to complete this process.

Step # 3 in completing alabama medicaid override form

Step 3: Always make sure that your details are right and then click "Done" to finish the process. After creating a7-day free trial account here, you'll be able to download request alabama pharmacy or email it immediately. The form will also be available from your personal account menu with your every edit. We do not share or sell any information you use whenever working with documents at our website.