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The form collects patient eligibility details and provider information across multiple sections, including urgent request criteria, prescribing and servicing provider data, medication and administration details, and lists of previous drugs tried. It also captures diagnostic information using ICD-9 or ICD-10 codes, requests supporting clinical documentation such as history and physical, labs, symptoms, and treatment history, and includes civil rights and language-assistance notices.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/aetna-oregon-prior-prescription-authorization-form-medical-exception/283750/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/aetna-oregon-prior-prescription-authorization-form-medical-exception/283750.png","ImageObject",442,249,{"name":88,"@type":89},"Margaret","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":25},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who should complete the prior authorization/precertification request form?","Question",{"text":108,"@type":109},"The provider should fill out the form. Before completion, confirm the patient’s benefits and eligibility.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How is an urgent request defined?",{"text":113,"@type":109},"An urgent request is one where a delay could seriously jeopardize the member’s life or health, or where the physician believes severe pain cannot be adequately managed without the requested care or treatment.",{"name":115,"@type":106,"acceptedAnswer":116},"What clinical information and ICD codes are required with the submission?",{"text":117,"@type":109},"Submit the medical rationale with supporting chart notes and labs, plus relevant history and physical, lab/radiology results, symptoms and functional impairments, and treatment history as appropriate. Provide all available ICD-9 or ICD-10 codes and descriptions, including primary/secondary/third diagnoses.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283750,1790222063,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":25,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":79},137451207643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","Medical Exception/  \n# Prior Authorization/Precertification*Request for Prescription Medications\n\nFor FASTEST service,call 1-855-240-0535,Monday-Friday,8a.m.to 6p.m.Central Time  \n\n| Instructions  \u003Cbr>This pre-authorization request form should be filled out by the provider.Before completing this form,please  \u003Cbr>confirm the patient's benefits and eligibility.Benefits for services received are subject to eligibility and plan  \u003Cbr>terms and conditions that are in place at the time services are provided.   |\n| --- |\n\n## Section 1 Submission\n\n\n| Patient Name   | Patient Insurance ID Number   | Physician name   | Today's Date   |\n| --- | --- | --- | --- |\n\n## Section 2 Review\n\n\n| s this request urgent?Defined as:A delay of service could seriously jeopardize the life or health of the member or the abbility of the member to regain maximum function.-  \u003Cbr>Or-In the opinion of a physician with knowledge of the membe's medical condition,would subject the member to severe pain that cannot be adequately managed without  \u003Cbr>the disputed care or treatment.If this request is urgent and meets the definition as indicated above,please check this box.  \u003Cbr>□Urgent Request  \u003Cbr>Date(MM/DD/YYYY):  \u003Cbr>Venify with the preauthorization ist at www.aetna.com/formulary,according to the company's procedure,or callthe number on the back of the member's card.  \u003Cbr>□Providing additional information  \u003Cbr>□Authorization extension  \u003Cbr>Is this request:□New  \u003Cbr>If you already have an authorization number,list it here:   |\n| --- |\n\n## Section 3 Patient Information\n\n\n| Name   |  |  |  | DOB (MM/DD/YYYY)   | Gender  \u003Cbr>□Female  \u003Cbr>□Male   |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Member ID Number   | Group Number   | Secondary Insurer Member ID Number   | Secondary Group Number   |  | Height   | Weight   |\n| Allergies   |  |  |  |  |  |  |\n\n\n| Section 4 Prescriber/Provider Information   |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Check one:   |  |  |  |  |  |\n| You are the □Requesting provider   | □Servicing provider   | □Specialty:_   |  |  |  |\n| Name   |  |  | Tax ID Number   | Phone   | Fax   |\n| Address   |  |  | City   | State   | ZIP Code   |\n| NPI Number   | DEA Number (if required)   |  | Whom should we contact if we require more information?  \u003Cbr>Phone:  \u003Cbr>Name:   |  |  |\n|  |  |  |  |  | Fax:_   |\n\n## Section 5 Patient's PCP Information (If applicable)\n\n\n| Name   | Phone   | Fax   |\n| --- | --- | --- |\n\n## Section 6 Medication/Medical &Dispensing Information\n\n\n| □New Therapy  \u003Cbr>□Renewal f RenewalDate therapy initiated:   |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| □IV  \u003Cbr>Route of administraton:□Oral/SL □Topical  \u003Cbr>□lnjection  \u003Cbr>□Other:   |  |  |  |  |  |\n| Administered:□Doctor's Office □Dialysis Center  \u003Cbr>□Other:  \u003Cbr>□Home Health  \u003Cbr>□By Patient   |  |  |  |  |  |\n| Medication Name   | Dose/Strength   | Frequency   | Length of Therapy   | Number of Refills   | Quantity   |\n|  |  |  |  |  |  |\n\nList of Previous Drugs Tried  \n\n| Drug Name   | Dosage   |\n| --- | --- |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n\n## Section7 Justification\n\nProvide the medical rationale for requested drug(include chart notes and supporting labs)and why a formulary alternative is not acceptable:  \n\n| Section 8   |  ICD Codes   |  |  |\n| --- | --- | --- | --- |\n| Provide all ICD-9or ICD-10 codes and their descriptions,if available;this will help us process your request.   |  |  |  |\n| Diagnosis:   |  |  |  |\n| Codes and descriptions are:□ICD-9 □ICD-10  \u003Cbr>Primary:_   |  |  | _____Second:___   ___Third:___   _   |\n\nSubmit the following clinical information with this form as appropriate for this request:  \n·History &Physical  \n·  Lab/radiology/testing results  \n·  Current symptoms and functional impairments  \n·  Treatment history  \nAny other information such as chart notes that support medical necessity for therequest:https://navinet.navimedix.com/Main.asp  \nAetna complies with applicable Federal civil rights laws and do","cbCaikLWDvzL9LE0","https://ap.wps.com/l/cbCaikLWDvzL9LE0","pdf",4866799,10,"English","# Instructions\n# Section 1 Submission\n# Section 2 Review\n# Section 3 Patient Information\n# Section 4 Prescriber/Provider Information\n# Section 5 Patient's PCP Information (If applicable)\n# Section 6 Medication/Medical & Dispensing Information\n# Section 7 Justification\n# Section 8 ICD Codes","[{\"question\":\"Who should complete the prior authorization/precertification request form?\",\"answer\":\"The provider should fill out the form. Before completion, confirm the patient’s benefits and eligibility.\"},{\"question\":\"How is an urgent request defined?\",\"answer\":\"An urgent request is one where a delay could seriously jeopardize the member’s life or health, or where the physician believes severe pain cannot be adequately managed without the requested care or treatment.\"},{\"question\":\"What clinical information and ICD codes are required with the submission?\",\"answer\":\"Submit the medical rationale with supporting chart notes and labs, plus relevant history and physical, lab/radiology results, symptoms and functional impairments, and treatment history as appropriate. Provide all available ICD-9 or ICD-10 codes and descriptions, including primary/secondary/third diagnoses.\"}]","Aetna Oregon Prior Prescription Authorization Form - Medical Exception | PDF",1789618711]