Aetna Prior Authorization Form

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AETNA BETTER HEALTH®
Prior Authorization Form
FIDA Phone: 1-855-494-9945
FIDA Fax: 1- 844 744-5618 or 1-844 744-5619
Date of Request: _______________________
For urgent requests (required within 24 hours), call Aetna Better Health New York at 1-855-456-9126
MEMBER
INFORMATION.…
Name: ______________________________________________________ ID Number ______________________
Date of Birth: __________________________Physician Name: ________________________________________
Other Insurance: ____________________________________________
Gender (circle one):
F
M
REQUESTING PHYSICIAN OR PROVIDER INFORMATION
Referring Provider / Requesting Provider
Place of Service or Facility Name
Name: ______________________________________ Name: _________________________________________
Address: ____________________________________ Address: ________________________________________
Telephone #: ________________________________
Telephone #: _____________________________________
Fax #: ______________________________________ Fax #: __________________________________________
Specialty: ___________________________________ Specialty: _______________________________________
National Provider Identification (NPI): ____________ National Provider Identification (NPI): ________________
Contact Person: _______________________________ Contact Person: __________________________________
REFERRAL / AUTHORIZATION
INFORMATION….
Problem / Diagnosis (ICD-9 Code(s)): ______________________________________________________________
_______________________________________________________________________________________________
Procedure / Test Requested (CPT Code(s)): _________________________________________________________
_______________________________________________________________________________________________
Date of Appointment or Service: ______________________ Number of Visits Required: ____________________
Type of Procedure (circle one):
Inpatient
Outpatient
In Office
Other Clinical Information - Include clinical notes, lab and X-ray reports, etc. (For procedures, please attach additional pages as
necessary.): _____________________________________________________________________________________

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