Get Gel Request Form

Filling out the Gel Request Form online is an essential step in obtaining precertification for the use of the Repository (H.P. ® Gel). This guide provides a clear, step-by-step approach to ensure that you complete the form accurately and efficiently.

Follow the steps to successfully complete the Gel Request Form online.

1. Click ‘Get Form’ button to access the Gel Request Form and open it in your editor.
2. Provide patient information in section A, which includes the first name, last name, address, date of birth, current weight, and contact information. Ensure all entries are clear and legible.
3. Fill in section B with insurance information. Include the Aetna Member ID number, group number, and whether the patient has other coverage. If there is other coverage, provide the necessary details.
4. Complete section C with prescriber information. Enter the prescriber's first and last name, address, phone number, email, license number, NPI number, and specialty.
5. In section D, provide dispensing provider information by indicating the place of administration and selecting the appropriate provider or pharmacy. Include any necessary contact details.
6. In section E, indicate that the request is for gel, and specify the dose and frequency required.
7. Complete section F by indicating the primary ICD-9 code for the diagnosis, as well as any secondary codes applicable.
8. Answer the question in section G regarding prior treatment with gel and provide the most recent treatment date if applicable.
9. Finally, complete section H by signing and dating the form to acknowledge the information provided is accurate.
10. Once the form is filled out, save your changes, and choose whether to download, print, or share the form as needed.

Begin completing your Gel Request Form online today to facilitate the precertification process.