Get Heparins Medication Request Form - Aetna

Filling out the Heparins Medication Request Form - Aetna online is a straightforward process that ensures your medication needs are addressed effectively. This guide will walk you through each section of the form, providing clear instructions to help you complete the request accurately.

Follow the steps to complete the form online:

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter today's date and the anticipated start date for the medication in the designated fields.
3. In the Patient Information section, fill in the patient's first name, last name, address, city, state, zip code, and contact numbers including home, work, and cell phone.
4. Provide the patient's date of birth, height, and weight, and list any known allergies.
5. Indicate where the medications should be shipped by selecting either home, work, or the doctor’s office.
6. Move to the Insurance Information section. Enter details about the primary insurance, including the Pharmacy Benefit Manager, policy number, group number, insured person's name, and phone number.
7. If applicable, fill in Medicare and Medicaid information by indicating 'Yes' or 'No' and providing relevant numbers.
8. For secondary insurance, repeat the procedure to supply policy number, group number, insured name, and phone number.
9. Fill in the Physician Information section with the prescribing physician's first name, last name, medical designation, address, city, state, zip code, phone, fax, state license number, National Provider Identifier (NPI), Drug Enforcement Administration (DEA) number, and UPIN.
10. Detail the relevant diagnosis, including primary and secondary diagnoses along with the corresponding ICD-9 codes.
11. In the Prescription section, select the required types, specify the doses, and indicate the number of refills needed.
12. Ensure you include any additional supplies needed for the patient to administer the medication.
13. Finally, the prescriber must sign the form to complete the request. If substitution is not permitted, they should write ‘NO SUBSTITUTION’ in the specified space.
14. Review all fields for completeness to avoid delays in therapy. Save any changes made, and download, print, or share the filled form as needed.

Complete your Heparins Medication Request Form online now!