INSTRUCTIONS: ALABAMA MEDICATION REQUEST FORM (MRF)

Participating physicians and providers treating an Alabama public employee and obtaining coverage for a Prior Authorization drug for which there is no available suitable alternative use the medication request form discussed in this article. This website can be found on the website maintained by the Retirement Systems of Alabama.

Alabama Medication Request Form (MRF) Step 1: Enter the patient name in the first blank box.

Alabama Medication Request Form (MRF) Step 2: Enter the patient insurance company and contract number in the second blank box.

Alabama Medication Request Form (MRF) Step 3: Enter the patient date of birth in the third blank box.

Alabama Medication Request Form (MRF) Step 4: Enter the diagnosis in the fourth blank box.

Alabama Medication Request Form (MRF) Step 5: Enter the physician's name and their specialty in the fifth blank box.

Alabama Medication Request Form (MRF) Step 6: Enter the physician's telephone number in the sixth blank box.

Alabama Medication Request Form (MRF) Step 7: Enter the physician's DEA number in the seventh blank box.

Alabama Medication Request Form (MRF) Step 8: Enter the physician's fax number in the eighth blank box.

Alabama Medication Request Form (MRF) Step 9: Enter the pharmacy used by the patient in the ninth blank box.

Alabama Medication Request Form (MRF) Step 10: Enter the pharmacy telephone number in the tenth blank box.

Alabama Medication Request Form (MRF) Step 11: Enter the drug requested in the eleventh blank box.

Alabama Medication Request Form (MRF) Step 12: Enter the quantity per month in the twelfth blank box.

Alabama Medication Request Form (MRF) Step 13: Enter the dose in the thirteenth blank box.

Alabama Medication Request Form (MRF) Step 14: Enter the length of treatment in the fourteenth blank box.

Alabama Medication Request Form (MRF) Step 15: Enter the drug strength in the fifteenth blank box.

Alabama Medication Request Form (MRF) Step 16: Enter the dosage form in the sixteenth blank box.

Alabama Medication Request Form (MRF) Step 17: Enter the reason for the medication request in the seventeenth blank box.

Alabama Medication Request Form (MRF) Step 18: Enter other medications tried and/or failed where indicated, as well as other pertinent history bearing on your request.

Alabama Medication Request Form (MRF) Step 19: Fax the form to the number at the top of the page.