Get Aetna Referral Form

Filling out the Aetna Referral Form online is an essential step for obtaining necessary medication and services. This comprehensive guide will help you navigate each section of the form, ensuring you provide all required information accurately.

Follow the steps to complete the Aetna Referral Form online.

1. Press the ‘Get Form’ button to access the Aetna Referral Form and open it in your preferred digital platform.
2. In the 'Today's Date' field, enter the current date to ensure your submission is up to date.
3. Fill in the 'Patient Information' section with the patient's first name, last name, address, city, state, ZIP code, home phone, work phone, cell phone, date of birth, height, weight, email address, and their desired shipping address for medications.
4. Complete the 'Allergies' section by listing any known allergies the patient has.
5. In the 'Insurance Information' section, provide details about the primary insurance, including the insurance company name, pharmacy benefit manager (PBM), policy number, group number, the name of the insured person, and their phone number. Indicate whether the patient has Medicare or Medicaid and provide respective numbers if applicable.
6. Fill out the 'Secondary Insurance' information, if applicable, including the policy number, group number, the insured person's name, and their phone number.
7. In the 'Physician Information' section, enter the first name and last name of the prescribing physician, their title (M.D., D.O., N.P., P.A.), address, city, state, ZIP code, phone number, fax number, state license number (St Lic. #), National Provider Identifier (NPI #), Drug Enforcement Administration (DEA #), and Unique Physician Identification Number (UPIN).
8. Provide the required diagnosis information, specifically indicating the clinical diagnosis code (e.g., 042 for HIV/AIDS) and additional clinical data such as CD4 count and viral load if applicable.
9. Select the medication(s) required by the patient and provide details such as strength, directions, quantity, and refill information as specified.
10. Ensure the prescriber signs the form in the designated area, including the instruction for substitution if necessary, and add the date of signing.
11. Once completed, users can save changes to the form, download or print it for submission, or share it with relevant parties as needed.

Complete the Aetna Referral Form online today to ensure timely access to your medications.