Transcription of Aetna Therapy Fax Request - orthonet-online.com
1 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.
2 If you receive this material / information in error, please contact the senderand delete or destroy the material / PlanCommercialMedicareTelephone Number()-Return Fax Number()-Facility NameZipStreet AddressCityStateOrthoNet Provider ID NumberProvide OrthoNet ID # ORAetna ID # IF NOT PAR with OrthoNetAetna Provider ID NumberFacility NPI NumberIndividual NPI NumberNational Provider Identifier (NPI) Aetna ID NumberREFERRING Physician'sPATIENT INFORMATIONM ember ID NumberFirst NameLast NameDate of Birth//MonthDayYearREQUEST INFORMATIONR equest for:Onset (Commencement) of Therapy ServicesExtension of Therapy ServicesOther Procedure: _____Service TypePhysical TherapyOccupational TherapyIs this Request for post-operative Therapy visits?YesNo Initial Evaluation Date//MonthDayYear(ICD-10 Format)Diagnosis Code5620656206
