Get Aetna Gr-67656 2017-2026

Filling out the Aetna GR-67656 form is an essential step for plan members wishing to appeal an internal coverage decision through an external review process. This guide provides clear instructions on how to complete the form accurately and efficiently.

Follow the steps to complete the Aetna GR-67656 form.

1. Press the ‘Get Form’ button to obtain the Aetna GR-67656 form and open it in your browser.
2. Begin by entering your personal information in the 'My Information' section. Provide your full name, Aetna member ID number, street address, city, state, ZIP code, and your home and mobile phone numbers.
3. In the 'My Provider’s Information' section, fill in the details of your healthcare provider. This includes the provider's name, street address, city, state, ZIP code, and office phone number. If applicable, include the provider's fax number as well.
4. Next, state the reason for your external review request in the 'External Review Request' section. Clearly mention the specific coverage denial you are appealing. Remember to attach a copy of the coverage denial letter and any other relevant documents that you believe will assist the reviewer.
5. In the 'Signature(s)' section, provide your signature to consent to the release of confidential medical information to the Independent Review Organization. If you have a legal representative, ensure their signature is included, along with their printed name, phone number, and the date of signature.
6. If you have an authorized representative assisting you, include their signature, printed name, and contact details. If their address differs from yours, include that information as well.
7. Finally, review all your entries for accuracy. Once completed, you may proceed to save changes, download a copy, print the form, or share it as needed.

Complete your Aetna GR-67656 form online today and take the next step in your appeal process.