Get Entyvio Medication Injectable Precertifcation Form - Aetna

Filling out the Entyvio Medication Injectable Precertification Form effectively is crucial for ensuring timely treatment. This guide provides a clear, step-by-step process to help you complete the form accurately online.

Follow the steps to complete your precertification form for Entyvio.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin with section A, patient information. Enter the patient’s first name, last name, date of birth, and address. Also, provide their home phone number, work phone number, and current weight.
3. In section B, insurance information, input the Aetna member ID, group number, and carrier name. If there is other coverage, check the appropriate box and provide the respective ID number.
4. Proceed to section C, prescriber information, where you will need to enter the prescriber's first and last name, phone number, and specialty. Ensure to fill in the dispensing provider information as well.
5. In section D, indicate the place of administration. Select from options such as self-administered, physician’s office, or outpatient infusion center, and provide the relevant contact details.
6. Complete section E with product information, including the dose and frequency of the medication requested for Entyvio.
7. Next, in section F, provide the diagnosis information. Include the primary ICD code and any secondary codes where applicable.
8. Move to section G to provide clinical information. Answer all questions regarding the patient's condition and treatment history entirely, as they are crucial for precertification.
9. Finally, complete section H with your signature and the date to acknowledge that all information provided is accurate.
10. Once all sections are filled out, review the form for accuracy, save your changes, and prepare to download, print, or share the completed document.

Get started on completing your Entyvio Medication Injectable Precertification Form online today.