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Click ‘Get Form’ to open the Precertification Request Form in our editor.
Begin by filling out Section A, 'Requesting Provider Information.' Enter the provider's name, ID number, contact name, telephone and fax numbers, and the request date.
Proceed to Section B, 'Patient Information.' Input the patient's name, date of birth, Aetna ID number, address, and telephone number.
In Section C, 'Nonparticipating Provider Information,' provide details about the nonparticipating provider including their name, contact information, specialty or ID number, and whether the patient has seen this provider before.
Move to Section D for 'Reason for Nonparticipating Provider Request.' Clearly outline the services needed, diagnosis codes, procedure codes, and explain why these services can only be provided by this specialist.
Finally, complete Section E by signing and dating the form. Ensure all fields are filled accurately before submission.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (45 Votes)
2013	4.3 Satisfied (284 Votes)

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