Form Gr 68744 – Fill Out and Use This PDF

Form Gr 68744 is an official document designed to provide information and record important administrative details. It offers users a reliable method for gathering essential data related to a special set of circumstances. This document serves several essential uses in order to streamline the administrative application process, such as providing legal custody or compensation for employees. Additionally, Form Gr 68744 ensures that the direction or planning of projects or activities runs smoothly and prioritizes the rights of all individuals involved. Completion of this document may be required before a particular project can begin, making its successful utilization paramount.

Form Gr 68744 PDF Details

In order to file your Form 68744, you will need to gather some important information first. This form is used to report the Cancellation of Debt (COD) income that was received in the previous year. You will need to know the amount of COD income you received, as well as the date it was received. In addition, you will need to provide information on any related expenses or deductions. With this information in hand, you can easily complete your Form 68744 and submit it to the IRS.

Question	Answer
Form Name	Form Gr 68744
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	ICD-9, aetna form gr 68744, Orlando, aetna gr 68744 form printable

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Viscosupplementation Injectable Medication	Aetna Precertification Notification
Viscosupplementation Injectable Medication	503 Sunport Lane, Orlando, FL 32809
Precertification Request	503 Sunport Lane, Orlando, FL 32809
Precertification Request	Phone:	1-866-503-0857
(Please complete all fields and return for precertification requests.)	FAX:	1-888-267-3277

Please indicate: Start of treatment Continuation of therapy:

Right knee

Left knee

both knees Today’s date:

Date of last treatment:

Date needed:

If ASRx is dispensing, ship to:

Doctor’s office

Patient

Other:

Phone:

Dispensing Provider:

Aetna Specialty Pharmacy®

Other:

Phone:

Fax:

TIN:

PIN:

Requesting medication administration code?

Yes

If yes, CPT Code:

20610

Other:

Precertification Requested By:

Phone:

Fax:

A. PATIENT INFORMATION

First Name:

Last Name:

Address:

City:

State:

ZIP:

Home Phone:

Work Phone:

Cell Phone:

DOB:

Allergies:

Email:

Patient Current Weight:

lbs

kgs

Patient Height:

inches or

cms

B. INSURANCE INFORMATION

Aetna Member ID #:

Does patient have other coverage?

Yes

Group #:

If Yes, provide ID#:

Carrier Name:

Insured:

Medicare: Yes

If Yes, provide ID #:

Medicaid:

Yes

If Yes, provide ID #:

C. PRESCRIBER INFORMATION

First Name:

Last Name:

(CIRCLE ONE): M.D. D.O. N.P. P.A.

Address:

City:

State:

ZIP:

Phone:

Fax:

St Lic #:

NPI #:

DEA #:

UPIN:

Provider Email:

Office Contact Name:

Phone:

Specialty (CHECK ONE):

Orthopedic

Primary Provider

Other:

D.DIAGNOSIS INFORMATION - Please indicate primary ICD-9 code and specify any other any other if applicable .

Primary ICD-9:

Other ICD-9 Code:

E.CLINICAL INFORMATION - All clinical questions must be completed for precertification request.


Requesting prior authorization for viscosupplementation therapy for:					Right knee		Left knee		both knees
Please indicate which drug you are requesting: (P is preferred, NP is non-preferred)
		Euflexxa® (P)	Hyalgan® (NP)	Orthovisc® (P)		Supartz® (NP)			Synvisc® (NP)	Synvisc One® (NP)
Yes	No	Does the patient have symptomatic osteoarthritis of the knee?
		If Yes, has this been documented in the patient’s medical record?						Yes	No
Yes	No	Has the patient had a documented failure after at least 3 months of conservative therapy (including physical therapy, pharmacotherapy, i.e.
		non steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and/or topical capsaicin cream) or unable to tolerate conservative therapy
		because of adverse side effects?
Yes	No	Has the patient failed to adequately respond to aspiration and injection of intra-articular steroids?
Yes	No	Does the patient report pain which interferes with functional activities (i.e., ambulation, prolonged standing)?
		If Yes, is the pain attributed to other forms of joint disease?					Yes	No
Yes	No	Does the patient have any contraindications to the injections (i.e., active joint infection, bleeding disorder)?
Yes	No	Does the patient have a contraindication to Euflexxa and Orthovisc?
		If Yes, please explain:

Yes Yes

Yes

	If requesting additional series of injections for patient: Date of last injection from prior series:	/	/
No	Did the patient respond adequately to the prior series of injections?
No	Does the patient’s medical record demonstrate a reduction in the dose of NSAIDs (or other analgesics or anti-inflammatory medication)
	during the period following the previous series of injections?
No	Does the patient’s medical record document significant improvement in pain and functional capacity as the result of the previous injections?

F.PRESCRIPTION – To be completed for precertification request. Prescriptions will be forwarded to Aetna Specialty Pharmacy unless otherwise noted.

MEDICATION - Refer to CPB # 0179	ASRx DISPENSING?		DIRECTIONS
Euflexxa (sodium hyaluronate 1%)

Hyalgan (sodium hyaluronate)

Orthovisc (high molecular weight form of hyaluronic acid)	Yes	No

Supartz (sodium hyaluronate)
Supartz (sodium hyaluronate)

Synvisc (hylan G-F 20)

Synvisc One (hylan G-F 20)

QUANTITY

*If Aetna Specialty Pharmacy is the dispensing pharmacy, patient benefits will be verified before product is shipped.
*If the prescriber is providing the drug, the provider must verify benefits.
Prescriber’s Signature:	Date:	/	/

(Required by law if Aetna Specialty Pharmacy is the dispensing pharmacy.)

Interchange is mandated unless practitioner writes the words “BRAND MEDICALLY NECESSARY” in this space:

Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure, defraud or deceive any insurance company by providing materially false information or conceals material information for the purpose of misleading, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

GR-68744 (9-12)

Form Gr 68744 – Fill Out and Use This PDF

Form Gr 68744 PDF Details

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