Prescription Drug Monitoring Program Pdm-Universal Claim Form - Alabama Department Of Public Health
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1ALABAMA DEPARTMENT OF PUBLIC HEALTH
PRESCRIPTION DRUG MONITORING PROGRAM
PDM-UNIVERSAL CLAIM FORM
The State of Alabama now requires that ALL Prescriptions for Schedule II – V Controlled Substances be reported to a data repository
managed by the Alabama Department of Public Health.
Fax: (888) 288-0337
Fax or Mail to
PO Box 3210
Phone: (800) 225-6998
Health Information Designs
Auburn, AL 36832-3210
PATIENT INFORMATION
First Name _____________________________________
MI ____
Last Name ___________________________________________________
SSN __________-_____-__________
Drivers License # _________________________ Drivers License State ______
DOB _____/_____/__________
Gender M F
Address _______________________________________________
City ___________________________
State _____
Zip _________
PHARMACY INFORMATION
Pharmacy Name _________________________________
NABP________________________
DEA _____________________________
Phone # (_________)_________-______________
Fax # (_________)_________-______________
Address _______________________________________________
City ___________________________
State _____
Zip _________
PRESCRIPTION INFORMATION
Prescription # 1
Rx # ____________________
Date Filled _____/_____/__________
Date Written _____/_____/__________
New Refill
-
-
NDC
Drug Name(Strength) ________________________________________________________
Quantity Dispensed ______________________
Days Supply ___________________________
# Refills Left _________________________
Prescriber Name ____________________________________
State License # ________________
DEA ______________________________
Prescriber Phone # (_________)_________-______________
Prescriber Fax # (_________)_________-______________
Written Rx
Faxed Rx
Phoned Rx
Prescription # 2
Rx # ____________________
Date Filled _____/_____/__________
Date Written _____/_____/__________
New Refill
-
-
NDC
Drug Name(Strength) ________________________________________________________
Quantity Dispensed ______________________
Days Supply ___________________________
# Refills Left _________________________
Prescriber Name ____________________________________
State License # ________________
DEA ______________________________
Prescriber Phone # (_________)_________-______________
Prescriber Fax # (_________)_________-______________
Written Rx
Faxed Rx
Phoned Rx
Prescription # 3
Rx # ____________________
Date Filled _____/_____/__________
Date Written _____/_____/__________
New Refill
-
-
NDC
Drug Name(Strength) ________________________________________________________
Quantity Dispensed ______________________
Days Supply ___________________________
# Refills Left _________________________
Prescriber Name ____________________________________
State License # ________________
DEA ______________________________
Prescriber Phone # (_________)_________-______________
Prescriber Fax # (_________)_________-______________
Written Rx
Faxed Rx
Phoned Rx
FOR HID USE ONLY
Date Received _____/_____/__________
Date Entered _____/_____/__________
Comments ______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
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