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Get Form 415 - Alabama Medicaid Agency - Medicaid Alabama

Atient Medicaid prescriptions be issued on tamper-resistant prescription paper. This form is designed to assist the Agency in coordinating educational efforts for noncompliant providers in conjunction with provider associations. Questions about this form or its use should be directed to the Medicaid Pharmacy Services Division at (334) 242-5050. Fill in the information and fax to: (334) 353-7014 Submitting Pharmacy should provide the following information for non-compliant prescribers (* denotes.

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