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Get And Sign Alabama Medicaid Override Form

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 NDC J Code Qty. requested per month CLINICAL INFORMATION Early Refill Maximum Unit/Maximum Cost Therapeutic Duplication Brand Limit Switch...

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