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Collects complete patient, insurance, prescriber, and dispensing/administration details, including start date, continuation information, and requested dose and frequency. Requires diagnosis coding (primary and secondary ICD codes) and condition-specific clinical documentation for approval criteria, with Medicare Advantage Part B instructions to use a separate Medicare request form.",{"@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/botox-precert-form-botox-onabotulinumtoxina-injectable-medication-precertification-request/287899/",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/botox-precert-form-botox-onabotulinumtoxina-injectable-medication-precertification-request/287899.png","ImageObject",442,249,{"name":88,"@type":89},"Ben ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required from the patient on this precertification request form?","Question",{"text":108,"@type":109},"The form requests patient demographics including first and last name, DOB, address, contact numbers, current weight and height, and allergy information, plus treatment start or continuation dates.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How are insurance details documented for precertification review?",{"text":113,"@type":109},"It requires Aetna member ID and group number when applicable, whether the patient has other coverage, and Medicare and Medicaid status and IDs if present.",{"name":115,"@type":106,"acceptedAnswer":116},"What clinical documentation is required for Botox precertification?",{"text":117,"@type":109},"Clinical sections require condition-specific criteria and documentation completeness, including primary diagnosis ICD code(s) and required answers for qualifying indications such as chronic migraine prophylaxis and other listed conditions.","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},287899,1790191928,{"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":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},2336478951081,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Botox® (onabotulinumtoxinA) Injectable Medication Precertification Request Page 1 of 3  \n(All fields must be completed and legible for precertification review.)  \nAetna Precertification Notification Phone: 1-866-752-7021 (TTY:711)  \nFAX:  1-888-267-3277  \nFor Medicare Advantage Part B: Please Use Medicare Request Form  \nPlease indicate:  Start of treatment: Start date  / /   \n Continuation of therapy, Date of last treatment  / /   \nPrecertification Requested By:   Phone:   Fax:    \n\n| A. PATIENT INFORMATION |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| First Name: |  |  |  | Last Name: |  |  |  |  |  | DOB: |  |\n| Address: |  |  |  |  | City: |  |  |  |  | State: | ZIP: |\n| Home Phone: |  | Work Phone: |  |  | Cell Phone: |  |  |  |  | Email: |  |\n| Patient Current Weight:   lbs or   kgs Patient Height:   inches or   cms |  |  |  |  |  |  |  | Allergies: |  |  |  |\n| B. INSURANCE INFORMATION |  |  |  |  |  |  |  |  |  |  |  |\n| Aetna Member ID \\#:   Group \\#:   Insured: |  |  | Does patient have other coverage?  Yes  No\u003Cbr>If yes, provide ID\\#:   Carrier Name:   Insured: |  |  |  |  |  |  |  |  |\n| Medicare:  Yes  No If yes, provide ID \\#: Medicaid:  Yes  No If yes, provide ID \\#: |  |  |  |  |  |  |  |  |  |  |  |\n| C. PRESCRIBER INFORMATION |  |  |  |  |  |  |  |  |  |  |  |\n| First Name: |  |  | Last Name: (Check One):  M. D.  D.O.  N. P.  P.A. |  |  |  |  |  |  |  |  |\n| Address: |  |  |  |  |  | City: |  |  |  | State: | ZIP: |\n| Phone: | Fax: |  | St Lic \\#: |  |  | NPI \\#: |  |  | DEA \\#: |  | UPIN: |\n| Provider Email: |  |  | Office Contact Name: |  |  |  |  |  |  | Phone: |  |\n| Specialty (Check one):  Dermatologist  Neurologist  Orthopedist  Otolaryngologist  Physiatrist  Other: |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |\n| D. DISPENSING PROVIDER/ADMINISTRATION INFORMATION |  |  |  |  |  |  |  |  |  |  |  |\n| Place of Administration:\u003Cbr> Self-administered  Physician’s Office\u003Cbr> Outpatient Infusion Center Phone:  \u003Cbr>Center Name:  \u003Cbr> Home Infusion Center Phone:  \u003Cbr>Agency Name:  \u003Cbr> Administration code(s) (CPT):  \u003Cbr>Address:   |  |  |  |  |  |  | Dispensing Provider/Pharmacy: (Patient selected choice)\u003Cbr> Physician’s Office  Retail Pharmacy\u003Cbr> Specialty Pharmacy  Other:   Name:   Address:   Phone:   Fax:   TIN:   PIN:   |  |  |  |  |\n| E. PRODUCT INFORMATION |  |  |  |  |  |  |  |  |  |  |  |\n| Request is for: Botox (onabotulinumtoxinA) Dose:   Frequency:  \u003Cbr>**Please note-requests over 400 units per day may require a medical exception review** |  |  |  |  |  |  |  |  |  |  |  |\n| F. DIAGNOSIS INFORMATION-Please indicate primary ICD code and specify any other where applicable. |  |  |  |  |  |  |  |  |  |  |  |\n| Primary ICD Code: Secondary ICD Code: Other ICD Code: |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |\n| G. CLINICAL INFORMATION-Required clinical information must be completed in its entirety for all precertification requests. |  |  |  |  |  |  |  |  |  |  |  |\n| For All Requests (clinical documentation required for all requests):\u003Cbr> Yes  No Is therapy prescribed for cosmetic purposes (e.g. , treatment of wrinkles or uncorrected congenital strabismus and no binocular fusion)?\u003Cbr> Achalasia\u003Cbr> Yes  No Has the patient tried and failed or is a poor candidate for conventional therapy such as pneumatic dilation and surgical myotomy?\u003Cbr> Yes  No Will the requested drug be prescribed by or in consultation with a gastroenterologist, proctologist, or colorectal surgeon?\u003Cbr> Blepharospasm\u003Cbr> Yes  No Has the patient been diagnosed with blepharospasm, including blepharospasm associated with dystonia, benign essential blepharospasmor VII nerve disorder?\u003Cbr> Yes  No Will the requested drug be prescribed by or in consultation with a neurologist or ophthalmologist?\u003Cbr> Cervical dystonia (e.g., torticollis)\u003Cbr> Yes  No Prior to initiating therapy with the requested drug, was/is there abnormal place","cbCaiuJv35GtXqhn","https://ap.wps.com/l/cbCaiuJv35GtXqhn","pdf",828583,"English","# Patient Information\n# Insurance Information\n# Prescriber Information\n# Dispensing Provider / Administration Information\n# Product Information\n# Diagnosis Information\n# Clinical Information","[{\"question\":\"What information is required from the patient on this precertification request form?\",\"answer\":\"The form requests patient demographics including first and last name, DOB, address, contact numbers, current weight and height, and allergy information, plus treatment start or continuation dates.\"},{\"question\":\"How are insurance details documented for precertification review?\",\"answer\":\"It requires Aetna member ID and group number when applicable, whether the patient has other coverage, and Medicare and Medicaid status and IDs if present.\"},{\"question\":\"What clinical documentation is required for Botox precertification?\",\"answer\":\"Clinical sections require condition-specific criteria and documentation completeness, including primary diagnosis ICD code(s) and required answers for qualifying indications such as chronic migraine prophylaxis and other listed conditions.\"}]","botox-precert-form - Botox (onabotulinumtoxinA) Injectable Medication Precertification Request | PDF",1789632864]