Forms for Health Care Professionals

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Applications and forms for health care professionals and their patients

Address/phone number changes

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.

Online provider directory update

Behavioral Health Precertification

ABA Requests: Assessment or Service Authorization
Transcranial Magnetic Stimulation (TMS)
BH Outpatient Nonpar Provider Request Form

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) requests
Medicare Appeals Provider Memo- Post Service
Member Complaint and Appeal
Practitioner and Provider Complaint and Appeal

Employee Assistance Program (EAP)

Dispute Resolution Request
Dispute Resolution Request - California
Electronic Claim Submission Application
Statement of Understanding

Medical Precertification

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
General prescription drug coverage determination (through SilverScript)

Aranesp^® (darbepoetin alfa)
Hepatitis C
Lidocaine Products (generic Lidoderm^®)
Linezolid (generic Zyvox®)
Modafinil and Armodafinil (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
CMS General Coverage Determination Request Form

Medicare Medical Specialty Drug and Part B Step Therapy Precertification forms

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

Behavioral Health Sample Forms
Diabetes Assessment Tool
Dilated Retinal Eye Exam
Pediatric Vaccine Record
Physician Communication
Post-Fragility Fracture Care
Specialist Consultation Report

Practice changes/Provider termination

If your'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 your're moving or changing jobs, you can sign a new agreement for your new practice or location.

Health care professional forms

Find a form

Address/phone number changes

Behavioral Health Precertification

Coordination of Benefits

Dispute and Appeals

Employee Assistance Program (EAP)

Medical Precertification

Medicare

Part D prescription drug prior authorizations and exceptions

Medicare Medical Specialty Drug and Part B Step Therapy Precertification forms

National Provider Identifier (NPI)

Network Application Requests

Patient Specific

Pharmacy

Physician Communications

Practice changes/Provider termination

Specialty Pharmacy Precertification (Commercial)

State Specific

News

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