Aetna Better Health Form Of New Jersey printable pdf download

Aetna Better Health Form Of New Jersey

Aetna Better Health® of New Jersey

3 Independence Way, Suite 400

Princeton, NJ 08540-6626

1-855-232-3596

AETNA BETTER HEALTH® OF NEW JERSEY

Medical day care/personal care assistant service authorization

request form

Fax completed form to 1-844-797-7601

☐Adult request

☐Pediatric request

Please check type of request:

☐Initial request

☐Re-authorization request

☐Facility/Provider transfer

☐Change in Managed Care Organization

Date submitted to Aetna Better Health of New Jersey: ______________________________________

lease provide the following member demographic information:

Member name: ____________________________________________________________________

Aetna Better Health of New Jersey Member ID #___________________ DOB: __________________

Member address (Street/City) _________________________________________________________

Member phone number: _____________________ Alternative phone number: _________________

Translation needed: Yes / No

If yes - language: _______________________________

Member Email address: ______________________________________________________________

Please provide the following information:

Current authorization expires on: _______________________________________________________

Requesting # days per week: ________ Requested number of hours/units per week: ______________

Has member had a lapse in service for 30 consecutive days during the prior authorization period?

Yes / No

Primary DX: _____________________

ICD-9 __________

Other Chronic Dx________________

NJ-15-04-22

Aetna Better Health Form Of New Jersey