Aetna dialysis form 2026

See details

4 out of 5

33 votes

The document is a precertification request form for injectable medications (Aranesp®, Epogen®, Procrit®) and outpatient dialysis treatment. It includes sections for patient information, insurance details, prescriber information, diagnosis and clinical data, prescription information, and lab values. The form is designed to gather necessary details for the approval of treatment related to anemia and chronic kidney disease.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out Aetna Dialysis Form with Our Platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the Aetna dialysis form in the editor.
Begin by entering the patient’s information in Section A. Fill in the first and last name, address, date of birth, and contact details. Ensure accuracy as this information is crucial for processing.
In Section B, provide the insurance information. Enter the Aetna Member ID and indicate if there is other coverage. If applicable, include details about Medicare or Medicaid.
Proceed to Section C for prescriber information. Fill out the prescriber’s name, address, phone number, and specialty. This section is vital for verifying treatment authorization.
In Section D, specify the diagnosis and clinical information. Indicate the primary ICD-9 code and answer all clinical questions thoroughly to support your request.
Complete Section E with lab values related to hemoglobin levels and any necessary tests. This data is essential for medication approval.
Finally, review all sections for completeness before signing in Section F. Ensure that all required fields are filled out accurately.

Start using our platform today to streamline your document editing and submission process for free!

See more aetna dialysis form versions

We've got more versions of the aetna dialysis form form. Select the right aetna dialysis form version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2010	4 Satisfied (33 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Does Aetna insurance cover dialysis?

Form 1095-A (Health Insurance Marketplace Statement) Its mailed to you in February. Need a copy? Log in to your Healthcare.gov account.

How to get Aetna 1095 a form?

Generally, you must get your health care coverage from your primary care provider () Your will issue referrals to participating specialists and facilities for certain services. For some services, your is required to obtain prior authorization from Aetna Medicare.

What insurance covers dialysis?

The most common types of health insurance for people on dialysis are: Medicare. More than 90% (9 out of 10) of Americans with kidney failure have Medicare. Private health insurance. Through an employer or the Affordable Care Act (ACA) health insurance marketplace, such as healthcare.gov. Medicaid.

Is dialysis included in insurance?

After you pay the annual Medicare Part B deductible, youll pay 20% of the cost of your treatment, while Medicare pays 80%. That coverage may include: Dialysis treatments and services you get in a Medicare-certified dialysis facility. Home dialysis equipment, supplies and support services.

Who is responsible for getting pre-authorization at Aetna?

You must file claims within 180 days from the date services were performed, unless theres a contractual exception.

Security and compliance

At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.

Learn more

Related forms

be ready to get more

Complete this form in 5 minutes or less

Get form

What happens if you cant afford dialysis?

Conclusion. People with kidney failure have to undergo dialysis regularly, which can be 2-3 times a week. The treatment can go on for months, putting severe strain on your finances. This is where critical illness insurance can help cover dialysis treatment costs and other associated expenses.

Aetna dialysis form 2026

Here's how it works