Get Gr 68425 Epo And Dialysis Precertification Request Form - Aetna

Filling out the GR 68425 EPO And Dialysis Precertification Request Form is an essential step in ensuring patients receive timely and appropriate care. This comprehensive guide will walk you through each section of the form, providing clear instructions for completing it online.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Fill in the treatment start date and the date of the last treatment in the appropriate fields.
3. Complete the patient information section by providing the first name, last name, address, city, state, ZIP code, date of birth, current weight, height, home phone, work phone, cell phone, and email address. Don’t forget to include any allergies.
4. In the insurance information section, enter the Aetna member ID and group number. Indicate whether the patient has other coverage and provide relevant ID numbers if applicable. Specify their Medicare and Medicaid status.
5. Fill in the prescriber information, including their first name, last name, address, city, state, ZIP code, phone, fax, licensing details, and email address. Indicate the provider’s specialty.
6. Provide details for the dispensing provider or administration information, including place of administration, agency names, and any other provider details.
7. If applicable, respond to the outpatient dialysis question and provide the CPT code.
8. Specify the product information, including the requested product and dosage/frequency.
9. Fill out the diagnosis information with the primary ICD-9 code and any additional codes as necessary.
10. Complete the clinical information and lab values, including hemoglobin levels and iron status. Ensure to note the date of the hemoglobin lab draw.
11. In the acknowledgement section, provide your name and signature to confirm that the information is accurate and complete.
12. Finally, review all entered information for accuracy. You can then save changes, download, print, or share the completed form as required.

Take action now and complete your GR 68425 EPO And Dialysis Precertification Request Form online.