Transcription of Aetna Therapy Fax Request - orthonet-online.com
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Aetna Therapy Fax Request - orthonet-online.com
Copyright 2 015 OrthoNet, LLCASP For Internal Office Use OnlyAetna Therapy Fax RequestFax Date: _____# of Pages Faxed: _____Please fax to OrthoNet at: (800) 477-4310 PLEASE USE THIS FORM FOR Aetna MEMBERSTHERAPY PROVIDER INFORMATIONI nstructions: 1. Use this form when requesting prior authorization of Therapy services for Aetna Please complete and Fax this Request form along with all supporting clinical documentation to OrthoNet at 1-800-477-4310. (This completed form should be page 1 of the Fax.)3. Please ensure that this form is a DIRECT COPY from the Please PRINT, in black ink, one character per box for ALL requested information and completely fill in each circle for selection where For assistance in completing this form, please call OrthoNet Provider Services Toll Free at (800) : The information transmitted is intended only for the person or entity to which it is addressed and maycontain CONFIDENTIAL material.
Copyright 2015 OrthoNet, LLC A S P For Internal Office Use Onl y Aetna Therapy Fax Request Fax Date: _____# of Pages Faxed: _____ Please fax …
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