Get Gr 68715 Precertification Request Form. Gr 68715 Precertification Request Form

The GR 68715 precertification request form is essential for obtaining approval for Ipilimumab (®) injectable medication. This guide will provide you with step-by-step instructions to ensure that you complete the form accurately and efficiently, facilitating a smoother precertification process.

Follow the steps to accurately complete the form

1. Click ‘Get Form’ button to obtain the form and open it in the designated editor.
2. Begin by filling in the patient information section. Include the patient's first name, last name, address, city, state, zip, and phone numbers. Also, record their date of birth, allergies, current weight, and height.
3. Next, complete the insurance information section. Provide the Aetna member ID number and indicate if the patient has other coverage. If applicable, fill in the group number, ID number, and details of the insured.
4. In the prescriber information section, fill out the prescriber's first and last name, address, phone numbers, state license number, provider email, and NPI number. Indicate the prescriber's specialty by checking the appropriate box.
5. Then, proceed to the dispensing provider/administration information. Specify the place of administration and dispensing provider or pharmacy details, including their phone numbers. Additionally, provide the administration code(s) as required.
6. Move on to the product information section. Clearly state that the request is for and fill in the dosage and frequency details as mandated.
7. In the diagnosis information section, indicate the primary ICD-9 code along with any secondary codes that apply.
8. Complete the clinical information section, addressing all questions, particularly around the use of in combination with and the specific stages of malignant melanomas relevant to the patient.
9. Lastly, ensure that the form is signed and dated in the acknowledgement section. This signature affirms that the information provided is accurate and true to your knowledge.
10. After completing all sections, save the changes to your form. You can choose to download, print, or share the finalized document as needed.

Begin filling out the GR 68715 precertification request form online today to ensure a smooth application process.