Referrals Submit Request

Sample Referrals Submit Request

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Sample Screen Page

Aetna Submit Referral

Member ID:

Patient Relationship:

Patient Date of Birth:

Required if Member ID is NOT an eight-character HMO ID or if patient is a dependent.

Dependent First Name:

Required only when multiple births on same day.

Referred BY Provider:

Referred TO Provider:

Taxonomy (Specialty) Code:

Location Code:

Number of Visits:

Diagnosis Codes:
At least one diagnosis
code must be supplied.

Procedure Codes:
At least one procedure
code must be supplied.

Notes:

Items in BOLD are required.

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