AetnaBetterHealth 2000MarketStreet,Suite850 Philadelphia,PA19103

AETNABETTERHEALTH Priorauthorizationrequestform

SERVICE(S)REQUESTED:Please PRINTLEGIBLYorTYPE.Please donotsubmitthisformwithoutsupportingclinical.

DME(checkoneifapplicable):RentalPurchase MEMBERINFORMATION Name: PCPName: DOB: Otherinsurance?: MemberID#: PolicyNumber: Gender(circleone):MorF PolicyHolder: PROVIDERINFORMATION OrderingPhysician/NursePractitioner: ServicingProvider/Facility/Physician: Name: Name: Address: Address: Tel: Tel: Fax: Fax: ContactPerson: Specialty: NPI: NPI: REQUIREDCLINICALINFORMATION Diagnoses(listCODES&description): 1. 3. 2. 4. Procedure/servicerequested(listallCPT/HCPCSCODES&descriptionsrequired): 1. 4. 2. 5. 3. 6. Date(s)ofservice: #ofunits/visits: ForHomeHealth(shiftcare)ONLY: Numberofhoursperday: Numberofdaysperweek:

(Telephone)18666381232(Fax)18773638120
REQUIREDDOCUMENTATION Pleaseattachsupportingclinicalinformation(e.g.,PlanofCare,medicalrecords,labreports,letter ofmedicalnecessity,progressnotes,etc).Requestsreceivedwithoutsupportingclinicalnotesand requiredcodesWILLNOTbereviewed. IFTHISISAREQUESTFORTHERAPY,PLEASEUSEASEPARATEFORMFOREACHSERVICE!(e.g.,one formforPTwithallcodesandclinical,oneformforOTwithallcodesandclinicaletc.)

www.aetnabetterhealth.com/pennsylvania

PA120502