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Get Aetna GR-68744 2020

L fields must be completed and legible for Precertification Review.) Please indicate: Start of treatment: Start date Precertification Requested By: / / For Medicare Advantage Part B: Phone: 1-866-503-0857 FAX: 1-844-268-7263 Continuation of therapy (Request Additional Series Below) Phone: Fax: A. PATIENT INFORMATION First Name: Last Name: Address: City: Home Phone: State: Work Phone: DOB: Allergies: Current Weight: lbs or ZIP: Cell Phone: Email: kgs Height: inches or cms.

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