Transcription of Keytruda® (pembrolizumab) Injectable Medication ...
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Keytruda® (pembrolizumab) Injectable Medication ...
GR-69035 (4-18)Keytruda ( pembrolizumab ) Injectable Medication precertification request Page 1 of 5 aetna precertification Notification503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX:1-888-267-3277 For Medicare Advantage Part B: FAX: 1-844-268-7263(All fields must be completed and legible for precertification Review.) Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last treatment / / precertification Requested By:Phone:Fax:A. PATIENT INFORMATIONF irst Name: Last Name: Address:City:State:ZIP:Home Phone: Work Phone: Cell Phone: DOB:Allergies:Email:Current Weight:lbs orkgsHeight:inches or cmsB. INSURANCE INFORMATIONA etna Member ID #:Group #:Insured:Does patient have other coverage? Yes NoIf yes, provide ID#: Carrier Name: Insured:Medicare: Yes No If yes, provide ID #: Medicaid: Yes No If yes, provide ID #: C.
GR-69035 (4-18) Keytruda® (pembrolizumab) Injectable Medication Precertification Request Page 1 of 5 Aetna Precertification Notification …
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