Get Aetna Gr-69265 2017

Filling out the Aetna GR-69265 form online is a crucial step in obtaining precertification for the medication. This guide provides clear and comprehensive instructions on how to complete each section of the form, ensuring a smooth and accurate submission process.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access the Aetna GR-69265 online form in the editor.
2. Begin with section A: Patient Information. Fill in the patient’s first name, last name, address, date of birth, and contact numbers. Provide information about any allergies, weight, and height.
3. Section B focuses on Insurance Information. Enter the Aetna Member ID number and any other applicable insurance details. Indicate if the patient has other coverage.
4. In section C, you will need to provide Prescriber Information including the prescriber’s first and last name, address, and contact details. Specify the prescriber's specialty by selecting the appropriate option.
5. For section D: Dispensing Provider/Administration Information, select the place of administration and provide details about the dispensing provider, including name, contact information, and address.
6. Section E requires the Product Information. Fill in the dosage of and provide directions for use.
7. In section F, indicate the primary ICD code for the diagnosis and any additional codes that may apply.
8. Complete section G: Clinical Information, by answering questions regarding the patient's history with and any contraindications.
9. If applicable, fill in the continuation requests in section G. Ensure to provide the patient's current BCVA information.
10. Finally, sign and date the acknowledgement section, confirming that all information provided is accurate and complete.
11. After reviewing all entered information for accuracy, save your changes. You can then download, print, or share the completed form as required.

Start the process of filling out the Aetna GR-69265 online now to ensure your precertification request is submitted promptly.