Get Aetna C17295-a 2019-2025

The Aetna C17295-A form is an essential document used for submitting prior authorization requests for medications. This guide will provide detailed, step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to fill out the Aetna C17295-A form online.

1. To begin, press the ‘Get Form’ button to obtain the Aetna C17295-A online form and open it for editing.
2. Start by filling out the member information section. Provide the member's name, date of birth, gender, member ID, city, state, height, and weight.
3. Next, complete the prescribing provider information. Include the provider's full name, specialty, NPI number, DEA number, office address, city, state, zip code, office contact, office phone, office fax, and the pharmacy's name, phone, and fax.
4. In the requested medication information section, indicate if there are any contraindications to formulary medications and confirm if the member has had a continued beneficial response to therapy.
5. For dispensing pharmacy information, choose whether this is a new request or a continuation of therapy request, and fill in the directions for use.
6. Provide the required strength, quantity, dosage form, day supply, and diagnosis for the medication request, as well as any medications the member has tried and failed.
7. Indicate the turn-around time for review, selecting either standard (24 hours) or urgent, if applicable.
8. Complete the clinical information section, answering all relevant questions about the member's health status, previous treatments, and any documentation requirements.
9. Add any additional information that the prescribing provider believes is important to the review.
10. Finally, sign and date the form, affirming that the information provided is true and accurate, and prepare to submit it.
11. Once you have filled out all sections of the form completely, save your changes, and then either download, print, or share the form as needed.

Complete the Aetna C17295-A form online today to ensure your request is processed smoothly.