Get Aetna Gr-69265 2020-2026

Filling out the Aetna GR-69265 form for precertification requests can seem daunting, but this guide provides clear, step-by-step instructions to make the process easier. You will be guided through each section of the form, ensuring you provide all necessary information accurately.

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

1. Click ‘Get Form’ button to access the Aetna GR-69265 form and load it in the editor.
2. Begin by filling in the patient information section. Provide the patient's first name, last name, address, city, home phone number, state, work phone number, date of birth, cell phone number, allergies, current weight, height, and ZIP code. Ensure all fields are completed accurately.
3. In the insurance information section, indicate if the patient has other coverage and, if applicable, provide the necessary ID numbers. Enter the member ID, group number, and specify if the patient is insured through Medicare or Medicaid.
4. Next, complete the prescriber information section. Fill in the prescriber’s first and last name, address, city, phone, fax, email, state license number, NPI number, DEA number, and office contact name. Make sure to select the appropriate specialty.
5. Proceed to the dispensing provider or administration information section. Indicate the dispensing provider or pharmacy, place of administration, and provide contact details and addresses as needed.
6. Fill out the product information section by specifying the request for (aflibercept), dose, and directions for use.
7. Complete the diagnosis information section, providing the primary ICD code and any additional ICD codes where applicable.
8. In the clinical information section, select the diagnosis and specify if the request is for continuation therapy. Answer the question about whether the patient has demonstrated a positive clinical response to therapy.
9. In the acknowledgment section, the person completing the form must sign and date it. Be aware of the statement regarding fraudulent insurance acts, confirming the intent to provide accurate information.
10. Once all sections are filled and verified for accuracy, save the changes, and download, print, or share the completed form as necessary.

Begin your process by completing the Aetna GR-69265 form online today.