Preauthorization nonparticipating provider 2025

1. Click ‘Get Form’ to open the preauthorization nonparticipating provider form in the editor.
2. Begin with Section A: Requesting Provider Information. Fill in your name, provider ID number, contact name, telephone number, fax number, and the request date.
3. Move to Section B: Patient Information. Enter the patient's name, date of birth, Aetna ID number, address, and telephone number.
4. In Section C: Nonparticipating Provider Information, provide details about the nonparticipating provider including their name, telephone number, address, fax number, specialty or provider ID number. Indicate if the patient has seen this provider before and when.
5. Proceed to Section D: Reason for Nonparticipating Provider Request. Clearly outline the services needed, diagnosis codes, procedure/CPT codes and explain why these services can only be provided by this specialist.
6. Finally, complete Section E by signing and dating the form to confirm its accuracy before submission.

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