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Legal Notices: Health benefits and health insurance plans contain exclusions and limitations.

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Applications and forms for health care professionals and their patients.

Behavioral Health Precertification: ABA Requests: Assessment or Service Authorization
Psychological or Neuropsychological Testing
OP Detoxification or OP Electroconvulsive Therapy (ECT)
Dispute and Appeals: Member Complaint and Appeal
Practitioner and Provider Complaint and Appeal
Employee Assistance Program (EAP): Dispute Resolution Request
Electronic Claim Submission Application
Statement of Understanding
ERA/EFT: EFT Only Enrollment
ERA and EFT Enrollment
Medical Precertification: Autolougous Chondrocyte Implantation
BRCA
Breast Reduction Surgery
Capsule Endoscopy
Dorsal Column Stimulator
Electroencephalographic (EEG) Video Monitoring
Gender Reassignment Surgery
Gynecologic Surgery Power Morcellation
Hip Surgery for Impingement Syndrome
Hyperbaric Oxygen Therapy (HBOT)
Initial Cochlear Implant
Obesity Surgery
Panniculectomy
Proton Beam Radiotherapy
Ptosis Surgery
Spinal Surgery
Uvulopalatopharyngoplasty (UPPP)
Varicose Vein Treatment
Wheelchairs and Power Operated Vehicles (Scooters)
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
Aranesp® (darbepoetin alfa)
Armodafinil (generic Nuvigil®)
Hepatitis C
Lidocaine 5% Patch (generic Lidoderm®)
Linezolid (generic Zyvox®)
Modafinil (generic Provigil®)
Oral ondansetron (oral generic Zofran®)
Procrit® (epoetin alfa)
Regranex® (becaplermin)
Sildenafil (generic Revatio®)
Tracleer® (bosetan)
Topical testosterone
Zolpidem tartrate (generic Ambien® immediate release)
Tier exception (cost-share reduction) request
Network Application Requests: Medical Request
National Provider Identifier (NPI): NPI Submission
NPI Exemption Notification
Patient Specific: Infertility Program Patient Registration
Physician Communications: We encourage you to send progress notes and discharge summaries to your patients’ other treating practitioners. Use these forms to help you communicate with other physicians.

Eye Examination Report Form

Physician Communication Form

Physician Communication Post-Fragility Fracture Care Form

Specialist Consultation Report

Behavioral Health/Medical Provider Communication Form
Provider Demographic Updates: Provider Demographic Updates
State Specific: Washington D.C. Uniform Consultation Referral (Appendix 43-1)

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Together, Aetna and Inova are taking a new approach to the way health care is offered. With this innovative partnership, these two industry leaders aim to provide more efficient and effective patient care at a more affordable cost. By joining the right medical professionals with the right technology, patients receive the benefit of quality, personalized health care.

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Behavioral Health Precertification

Dispute and Appeals

Employee Assistance Program (EAP)

ERA/EFT

Medical Precertification

Medicare

Part D prescription drug prior authorizations and exceptions

Network Application Requests

National Provider Identifier (NPI)

Patient Specific

Physician Communications

Provider Demographic Updates

State Specific

The Partnership

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