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Get Aetna Gr-67353-12 2014-2026
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How to fill out the Aetna GR-67353-12 online
Filling out the Aetna GR-67353-12 form online can be a straightforward process when approached step-by-step. This guide provides clear instructions to help you navigate each section of the form with ease.
Follow the steps to complete the Aetna GR-67353-12 form efficiently.
- Click the 'Get Form' button to access the Aetna GR-67353-12 form and open it in your preferred document editor.
- In Section A, input the requesting provider information. This includes the provider's name, provider ID number, contact name, telephone number, fax number, and the date of the request.
- Proceed to Section B to enter patient information. Fill in the patient’s name, date of birth, Aetna ID number, address, and telephone number.
- In Section C, provide details about the nonparticipating provider. Enter their name, telephone number, address, fax number, specialty or provider ID number, and indicate whether the patient has seen this provider in the past, including the last visit date if applicable.
- Move on to Section D to specify the reason for the nonparticipating provider request. List the services needed, enter diagnosis codes and procedure/CPT codes, and explain why these services can only be provided by this particular specialist.
- Continue in Section D by indicating if this request follows any recent emergency room treatment or surgery, noting the last visit date if applicable.
- In the same section, confirm if this is a request for nonparticipating provider coverage at in-network benefits level, and if you have attempted to find an Aetna network provider.
- Conclude by completing the signature field in Section E. Sign the form and indicate the date it was completed.
- Once all fields are filled out, you can save your changes, download the completed form, print it for physical submission, or share it as required. Ensure that you mail or fax it to the address or number provided at the top right corner of the form.
Start filling out your Aetna GR-67353-12 form online today for a smooth submission process.
To use your Aetna extra benefits card, simply present it at the participating provider or retailer. This card allows you to access additional benefits not covered under your standard plan. If you have the Aetna GR-67353-12 plan, make sure to review the extra benefits guide available online. This guide will clarify what services you can use your card for.
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