Get Aetna Dialysis Form

Filling out the Aetna Dialysis Form online is a straightforward process that enables users to efficiently submit their dialysis treatment requests. This guide provides clear, step-by-step instructions to ensure accurate completion of the form, helping users navigate each section with confidence.

Follow the steps to fill out the Aetna Dialysis Form online:

1. Press the ‘Get Form’ button to access the Aetna Dialysis Form and open it in your preferred editor.
2. Begin with the date fields; indicate the start of treatment or continuation of therapy along with today’s date.
3. Provide the dispensing provider's information for the medication request, including the name and phone number of the provider.
4. If applicable, indicate whether outpatient dialysis treatment is requested; if yes, supply the corresponding CPT code.
5. Complete section A by filling in patient information, including their first and last name, address, phone numbers, date of birth, allergies, weight, and height.
6. In section B, enter insurance information including the Aetna member ID, group number, and whether the patient has additional coverage.
7. Section C requires prescriber information; include the prescriber’s first and last name, title, address, and contact details.
8. Provide diagnosis and clinical information in section D by entering the primary ICD-9 code and answering all relevant questions.
9. In section E, input laboratory values as needed, including hemoglobin levels and dates of lab draws.
10. Conclude by reviewing all information for accuracy, then save your changes. Users may choose to download, print, or share the completed form.

Begin filling out the Aetna Dialysis Form online to ensure your request is processed smoothly.