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I will be supervising the patient s treatment. Supporting documentation is available in the patient record. Prescribing Practitioner Signature Date CLINICAL INFORMATION Drug requested J Code If applicable Qty. Initial Request Strength Days supply Diagnosis or ICD-9 Code r PA Refills 0 1 2 3 4 5 Other Renewal Maintenance Therapy r Acute Therapy Medical justification r Additional medical justification attached* Medications received through coupons and samples are not acceptable as justification* ...

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (92 Votes)
2015	4.4 Satisfied (53 Votes)
2008	4 Satisfied (33 Votes)

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Does CT need prior authorization?

Radiology exams that may require pre-authorization include: Bone Mineral Density exams ordered more frequently than every 23 months. CT scans (all diagnostic examinations) MRI/MRA (all examinations)

What does Alabama family planning Medicaid cover?

Eligible women qualify for most family planning services and supplies, including birth control pills, the shot, vaginal ring, diaphragm and contraceptive patch, doctor/clinic visits (for family planning only) and tubal ligations.

What is Alabama Medicaid group number?

Contacts for Providers Main Address301 Technacenter Drive, Montgomery, AL 36117Provider Assistance Center(800) 688-7989 (Nationwide Toll-Free)Provider Enrollment(888) 223-3630 (Nationwide Toll-Free)6 more rows

Does Medicaid cover mammograms in Alabama?

Free services include a pelvic exam, pap smear, clinical breast exam, mammogram, and diagnostic services such as an ultrasound, colposcopy, or biopsy, if needed.

What procedures does Medicare require prior authorization?

Under Medicare Advantage, services requiring prior authorization typically include durable medical equipment, prescription drugs, and skilled nursing facility stays.

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