Get Aetna Gr-69265 2021-2025

Filling out the Aetna GR-69265 form for ® (aflibercept) precertification is an important process for ensuring proper treatment coverage. This guide provides a clear, step-by-step approach to completing the form accurately and efficiently online.

Follow the steps to complete the Aetna GR-69265 form online.

1. Click the 'Get Form' button to obtain the Aetna GR-69265 form and open it for editing.
2. Indicate the start of treatment by entering the start date in the designated fields.
3. Provide the continuation of therapy date if applicable, filling in the date of the last treatment.
4. Complete the precertification requested by section with your name and contact information.
5. Fill out the patient information section, ensuring all fields are complete and legible. This includes the patient's first name, last name, address, contact numbers, and date of birth.
6. Move on to the insurance information section. If the patient has other coverage, be sure to provide the relevant IDs and check the appropriate boxes.
7. Fill in the prescriber information, including the prescriber's name, address, contact details, and specialty.
8. In the dispensing provider or administration information section, provide details of the selected dispensing provider or pharmacy.
9. For product information, indicate that the request is for (aflibercept), and specify the dose and directions for use.
10. Complete the diagnosis information by providing the primary ICD code and any applicable secondary ICD code.
11. In the clinical information section, select the appropriate diagnosis and answer questions regarding prior treatments and the patient's clinical response.
12. In the acknowledgment section, ensure the request is signed and dated appropriately.
13. Finally, review all entries for accuracy and completeness. You can then save changes, download, print, or share the completed form as needed.

Complete your Aetna GR-69265 form online today to ensure timely precertification for treatment.