Health Care Professional Forms
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Applications and forms for health care professionals and their patients
Behavioral Health Precertification
Coordination of Benefits
Dispute and Appeals
For Part D prior authorization forms, please see the Medicare section.
Authorized Representative Request
Medicare Member Authorization Appeal -appealing Medicare denials of medical prior authorization (precertification) requestsMedicare Appeals Provider Memo- Post Service
Member Complaint and Appeal
Practitioner and Provider Complaint and Appeal
Employee Assistance Program (EAP)
Medical Precertification
Autolougous Chondrocyte Implantation
BRCA
Breast Reduction and/or Reconstructive Surgery
Dorsal Column Stimulator
Electroencephalographic (EEG) Video Monitoring
Gender Reassignment Surgery
Gender Reassignment Surgery - Aetna Student Health
Hip Surgery for Impingement Syndrome
Hyperbaric Oxygen Therapy (HBOT)
Infertility Services
Initial Cochlear Implant
Lower Limb Prosthesis including Microprocessor-Controlled Knee
Obesity Surgery
Panniculectomy
Proton Beam Radiotherapy
Ptosis Surgery
Sinus Surgery
Skilled Home Private Duty Nursing Care
Spinal Surgery
Uvulopalatopharyngoplasty (UPPP)
Varicose Vein Treatment
Wheelchairs and Power Operated Vehicles (Scooters)
Whole Exome Sequencing (WES)
Medicare
Hospital Discharge Appeal Notices
(Note: This is a page on the CMS site that provides information about patient rights as a hospital inpatient. The page includes detailed information and links to CMS forms.)
Part D prescription drug prior authorizations and exceptions
General prescription drug coverage determination
Prescription drug appeal form
Aranesp® (darbepoetin alfa)
Armodafinil (generic Nuvigil®)
Hepatitis C
Lidocaine 5% Patch and Ointment (generic Lidoderm®)
Linezolid (generic Zyvox®)
Modafinil (generic Provigil®)
Oral ondansetron (oral generic Zofran®)
Procrit® (epoetin alfa)
Regranex® (becaplermin)
Sildenafil (generic Revatio®)
Topical Testosterone
Tracleer® (bosetan)
Zolpidem tartrate (generic Ambien® immediate release)
Tier exception (cost-share reduction) request
Network Application Requests
National Provider Identifier (NPI)
Patient Specific
Pharmacy
Mail Service Order Form (English)
Mail Service Order Form (Spanish)
Prescription Medication Claim (English)
Prescription Medication Claim (Spanish)
Prescription Medication Precertification
Opioid addiction treatment: For Aetna’s commercial plans, there is no precertification required for buprenorphine products.
Part D forms: Please see the Medicare section of this page.
Physician Communications
Address/phone number/practice changes
Relocating, retiring, job changes
If you’re retiring, moving out of state, or changing provider groups, use this form to notify us. We’ll need to terminate your existing agreement with us. If you’re moving or changing jobs, you can sign a new agreement for your new practice or location.
This form also will update your information in the online provider directory.
Provider termination form and directory update
Other directory updates
To change your phone or fax number, email address or practice address, use the link below. If your changes result from an out-of-state move or a change of provider group, please use the form above instead.
Specialty Pharmacy Medications
Medication Request (General)
Crohns/Ulcerative Colitis Medication Request
Enzyme Replacement Medication Request
Growth Hormone Medication Request
Hemophilia Medication Request
Hepatitis C Medication Request
HIV Medication Request
Immune Globulin Medication Request
Infertility Medication Request
Multiple Sclerosis Medication Request
Oral Oncology Medication Request
Osteoporosis Medication Request
Psoriasis Medication Request
Rheumatoid/Psoriatic/Juvenile Arthritis and Ankylosing Spondylitis Medication Request
Synagis Medication Request
Synagis® Reorder Form
Transplant Medication Request
Viscosupplementation Medication Request
Vivitrol Reorder Form
Specialty Pharmacy Precertification
Actemra® (Tocilizumab) Precertification Request
Adcetris® (Brentuximab Vedotin) Injectable Medication Precertification Request
Alpha 1 Antitrypsin Inhibitor Therapy Precertification Request
Aubagio® (Teriflunomide) Medication Precertification Request
Avonex® (Interferon Beta-1a) Medication Precertification Request
Bavencio®(Avelumab) Medication Precertification Request
Benlysta®(Belimumab) Injectable Medication Precertification Request
Besponsa®(Inotuzumab Ozogamicin) Medication Precertification Request
Betaseron®(Interferon beta-1b) Medication Precertification Request
Botulinum Toxins Medication Precertification Request
Cimzia® (Certolizumab) Precertification Request
Cinqair® (Reslizumab) Medication Precertification Request
Copaxone® or Glatopa™ (Glatiramer Acetate) Medication Precertification Request
Cosentyx® (Secukinumab) Injectable Medication Precertification Request
Crysvita® (burosumab-twza) Injectable Medication Precertification Request
Cyramza® (Ramucirumab) Medication Precertification Request
Darzalex™ (Daratumumab) Medication Precertification Request
Diabetic Testing Supplies Prior Authorization Request Form
Emend® (Fosaprepitant) Injectable Medication Precertification Request
Empliciti™ (Elotuzumab) Medication Precertification Request
Enbrel® (Etanercept) Precertification Request
Entyvio® (Vedolizumab) Injectable Medication Precertification Request
Enzyme Replacement Precertification Request
EPO/Dialysis medication precertification Request
Erbitux® (Cetuximab) Injectable medication precertification Request
Exondys51® (Eteplirsen) Injectable Precertification Request
Extavia® (Interferon beta-1b) Medication Precertification Request
Eylea® (Aflibercept) Injectable Precertification Request
Fasenra™ (Benralizumab) Injectable Medication Precertification Request
Forteo®(Teriparatide) Injectable Medication Precertification Request
Fulphila™ (pegfilgrastim-jmdb) Medication Precertification Request
Gattex® (Teduglutide) Injectable Medication Precertification Request
Gazyva® (Obinutuzumab) Injectable Medication Precertification Request
Gilenya® (Fingolimod) Medication Precertification Request
Granix® (tbo-filgrastim) Medication Precertification Request
Growth Hormone Medication Request (Adult)
Growth Hormone Medication Request (Pediatric)
Hep C Medication Precertification Request
Hereditary Angioedema Medication Precertification Request
H.P Acthar Gel (Repository Corticotropin) Medication Precertification Request
Humira® (Adalimumab) Precertification Request
Ilaris® (Canakinumab) Injectable Medication Precertification Request
Imfinzi® (Durvalumab) Injectable Medication Precertification Request
Imlygic™ (Talimogene Laherparepvec) Medication Precertification Request
Immune Globulin (IG) Therapy Medication Precertification Request
Infertility Medication Precertification Request (Female)
Infertility Medication Precertification Request (Male)
Inflectra® (Infliximab) Injectable Medication Precertification Request
Insulin-Like Growth Factor-1 Injectable Medication Precertification Request
Kevzara®(Sarilumab) Medication Precertification Request
Keytruda®(Pembrolizumab) Injectable Medication Precertification Request
Kineret® (Anakinra) Precertification Request
Krystexxa® (Pegloticase) Injectable Medication Precertification Request
Lartruvo™ (Olaratumab) Medication Precertification Request
Lemtrada® (Alemtuzumab) Medication Precertification Request
Leukine® (sargramostim) Medication Precertification Request
Levoleucovorin (Fusilev®, Khapzory™) Injectable Medication Precertification Request
Libtayo® (cemiplimab) Medication Precertification Request
Lucentis® (Ranibizumab) Injectable Medication Precertification Request
Lumoxiti™ (moxetumomab pasudotox)) Medication Precertification Request
Luxturna ® (Voretigene Neparvovec-rzyl) Medication Precertification Request
Macugen® (Pegaptanib Sodium) Injectable Medication Precertification Request
Makena® (Hydroxyprogesterone Caproate) Medication Precertification Request
Miacalcin® (Calcitonin) Medication Precertification Request
Myalept® (Metreleptin) Injectable Medication Precertification Request
Natpara® (rhPTH1-84) Injectable Medication Precertification Request
Neulasta® (pegfilgrastim) Medication Precertification Request
Neupogen® (filgrastim) Medication Precertification Request
Nivestym™ (filgrastim-aafi) Precertification Request
Nucala® (Mepolizumab) Injectable Medication Precertification Request
Ocrevus™ (Ocrelizumab) Medication Precertification Request
Olumiant® (baricitinib) Medication Precertification Request
Onpattro® (patisiran) Injectable Medication Precertification Request
Opdivo® (Nivolumab) Injectable Medication Precertification Request
Orencia® (Abatacept) Precertification Request
Otezla® (Apremilast) Medication Precertification Request
Parsabiv™ (Etelcalcetid) Medication Precertification Request
Praluent™ (Alirocumab) Injectable Medication Precertification Request
Plegridy® (Peginterferon Beta-1a) Medication Precertification Request
Prolia®, Xgeva® (Denosumab) Medication Precertification Request
Provenge Medication Precertification Request
Pulmonary Arterial Hypertension (Oral Medications) Precertification Request
Radicava™ (Edaravone) Medication Precertification Request
Rebif® (Interferon Beta-1a) Medication Precertification Request
Remicade® (Infliximab) Precertification Request
Renflexis ® (Infliximab-abda) Injectable Medication Precertification Request'
Repatha™ (Evolocumab) Injectable Medication Precertification Request
Rituxan® (Rituximab) Precertification Request
Siliq™ (Brodalumab) Medication Precertification Request
Simponi® (Golimumab) Precertification Request
Simponi Aria® (Golimumab) Infusion Medication Precertification Request
Soliris® (Eculizumab) Medication Precertification Request
Spinzara® (Nusinersen) Injectable Precertification Request
Spravato™ (esketamine) Medication Precertification Request
Stelara® (Ustekinumab) Precertification Request
Strensiq™ (Asfotase alfa) Injectable Medication Precertification Request
Synagis® (Palivizumab) Injectable Medication Precertification Request
Taltz® (Ixekizumab) Injectable Medication Precertification Request
Tecentriq™ (Atezolizumab) Medication Precertification Request
Tecfidera® (Dimethyl Fumarate) Medication Precertification Request
Tegsedi™ (inotersen) Medication Precertification Request
Tremfya® (Guselkumab) Medication Precertification Request
Tymlos™ (Abaloparatide) Medication Precertification Request
Tysabri® (Natalizumab) Medication Precertification Request
Udenyca™ (pegfilgrastim-cbqv) Precertification Request
Ultomiris™ (ravulizumab-cwvz) Precertification Request
Vectibix® (Panitumumab) Injectable medication precertification Request
Viscosupplementation Injectable Medications Precertification Request
Xeljanz® (Tofacitinib) Medication Precertification Request
Xofigo® (Radium-223 dichloride) Injectable Medication Precertification Request
Xolair®(Omalizumab) Medication Precertification
Yervoy® (Ipilimumab) Injectable Medication Precertification Request
Zarxio® (filgrastim-sndz) Medication Precertification Request
Specialty Medication Precertification Request Form (General)
State Specific
California Prescription Drug Prior Authorization
Colorado Prescription Drug Prior Authorization
Connecticut Accident Detail Questionnaire
Iowa Prescription Drug Prior Authorization
Louisiana Prescription Drug Prior Authorization
Massachusetts Prescription Drug Prior Authorization
Massachusetts Standard Hepatitis C Prior Authorization
Massachusetts Standard Synagis Prior Authorization
Michigan Prescription Drug Prior Authorization
New Hampshire Prescription Drug Prior Authorization
New Jersey Appeal a Claim Determination
Ohio Electronic Funds Transfer (EFT) Opt Out
Oregon Prescription Drug Prior Authorization
Texas Prescription Drug Prior Authorization
Texas Standard Prior Authorization
Texas Telemedicine and Telehealth Services Reimbursement Policy
Washington Intent to Use a Substitute Provider
Washington D.C. Uniform Consultation Referral (Appendix 43-1)