Fill and Sign the Boise School District Physical Form

Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 Denosumab (XGEVA®) Injectable Medication Precertification Request Please indicate: Start of treatment Ship to: Doctor’s office Patient Continuation of therapy Date needed: Phone: ® Dispensing Provider: Today’s date: Other: Aetna Specialty Pharmacy or Other: Phone: Fax: TIN: Precertification Requested By: PIN: Phone: A. PATIENT INFORMATION First Name: Last Name: Address: Fax: City: Home Phone: State: Work Phone: DOB: Cell Phone: Allergies: Patient Current Weight: B. INSURANCE INFORMATION Email: lbs or kgs Aetna Member ID #: Group #: Insured: Medicare: Yes No If yes, provide ID #: C. PRESCRIBER INFORMATION First Name: Address: Patient Height: Does patient have other coverage? If yes, provide ID#: Insured: Medicaid: Yes inches or Fax: cms Yes No Carrier Name: No If yes, provide ID #: Last Name: (Circle one): M.D. D.O. N.P. P.A. City: Phone: Provider Email: State: St. Lic. #: NPI #: Oncologist Hematologist Internal Medicine ZIP: DEA #: UPIN: Phone: Office Contact Name: Specialty (Circle one): ZIP: Other: D. DIAGNOSIS INFORMATION Primary ICD-9: 170.0-170.9 Malignant Neoplasm of Bone and Articular Cartilage 185.0 Malignant Neoplasm of Prostate 198.5 Secondary Malignant Neoplasm/Bone and Bone Marrow Other ICD-9 Code: E. CLINICAL INFORMATION Yes No Does the patient have confirmed bone metastases from solid tumors? F. PRESCRIPTION INFORMATION – To be completed only if Aetna Specialty Pharmacy is Dispensing Provider MEDICATION STRENGTH DIRECTIONS QUANTITY REFILLS XGEVA CPB # 0804 *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: (Required by law if Aetna Specialty Pharmacy is the dispensing pharmacy.) Interchange is mandated unless practitioner writes the words “NO SUBSTITUTION” in this space: GR-68694 (1-11) Date: / /