Aetna Referral Form Printable

You and your staff can find all the forms you need all in one place so you can focus on patient care.

Aetna referral form printable. Discover all of our resources for health care professionals and join the aetna providers network. Complete items one 1 through nineteen 19. Aetna managed dental specialty referral form for dmo please see reverse side for additional information. A participating aetna provider designated as a pcp note.

A referral isnt a substitute for a service that requires precertification. R pod i if submitting a universal claim form for payment or specialty approval this referral form must be included. For those that previously received their form 1095 b in the mail you can receive a copy of your 2019 form 1095 b by going out to the aetna member website in the message center under the letters and communications tab or by sending us a request at aetna po box 981206 el paso tx 79998 1206. For faster easier submission of claims the provider may contact the aetna claim processing center for information regarding electronic claim submissions.

The pcp making the referral must participate in the members benefits plan. Build relationships while helping patients with aetna. Print a prescription drug claim form print a prescription drug claim form spanish print and complete this form for medical dental vision hearing or vaccine reimbursement. Texas standard prior authorization request form for health care services mail this form to.

Browse through our extensive list of forms and find the right one for your needs. To request a referral you must be. Skip to main content. Fill out this form if you were billed directly by a provider and would like to request reimbursement for medical care includes dental vision hearing and vaccines.

To obtain a review submit this form as well as information that will support your appeal which may include medical records office notes discharge summaries lab records andor member history this is not an all inclusive list to the address listed on your explanation of benefits eob or other correspondence received from aetna. Part ii complete only if claim is for a dependent patients name last first mi if a dependent male dependent status. Find aetna health care professional forms here. Practices currently contracted with aetna better health can update or change their information by submitting an online form.

P o box 14079 lexington ky 40512 4079 for fastest service call 1 888 632 3862 monday friday 800 am to 600 pm central time. Find a form.