Get Aetna Gr 69033 9 15 Form

The Aetna Gr 69033 9 15 Form is essential for precertification requests regarding (). This guide will provide you with step-by-step instructions for completing the form online effectively and accurately.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's first name, last name, address, home phone number, current weight, and date of birth.
3. In the 'Insurance Information' section, provide details such as the Aetna member ID number, group number, and check if the patient has other coverage. If applicable, include the ID number.
4. Complete the 'Prescriber Information' section by entering the prescriber's first name, last name, address, phone number, fax number, email, and specialty.
5. Fill out the 'Dispensing Provider/Administration Information' section. Indicate the place of administration, providing the name and phone number of the dispensing provider.
6. In the 'Product Information' section, specify the request for , including the dose and frequency.
7. Complete the 'Diagnosis Information' section by indicating the primary ICD-9 code, and if there are any other applicable codes.
8. Thoroughly fill out the 'Clinical Information' sections. Answer the questions regarding Crohn's Disease, Ulcerative Colitis, Psoriasis, Rheumatoid Arthritis, and other relevant conditions.
9. End with the 'Acknowledgement' section, where the request must be signed and dated. Ensure all fields have been completed for a successful submission.
10. Once all necessary information has been recorded, review the form for accuracy, save changes, and proceed to download, print, or share the completed form as needed.

Ensure your submission is complete by filing the Aetna Gr 69033 9 15 Form online today.