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Medical, Dental and Vision Claim Forms

Health care professionals in our network should file claims for you. (Some who are not in the network may also submit claims for you.) Ask your doctor or other health care professional if you need to submit a claim.

If you get a bill or receive care from a health care professional who is not in the network, and you need to submit a claim, please complete and mail one of the forms below to the address on your ID card.

• Medical Claim Form   (PDF, 199 KB)
• Dental Claim Form   (PDF, 431 KB)
• Spanish Dental Claim Form   (PDF, 440 KB)
• Vision Claim Form  (PDF, 248 KB)

Pharmacy Forms

During an emergency or when traveling, you may have to use a pharmacy that is not in our network. In this case, you must file a paper claim  (PDF, 370 KB). Mail the completed form to the address on your ID card.

Aetna Rx Home Delivery® Brochures & Order Forms

Save time and money. Order your prescriptions through Aetna Rx Home Delivery. To download a brochure or order form, log-in to your secure member website. Choose "Pharmacy Benefits" under Related Shortcuts. Then click on "Order prescriptions or check order status online" to find brochures and order forms.

Flexible Spending Account Forms

Before submitting a Health Care Reimbursement  (PDF, 335 KB) request, please read about health care expenses.

Flexible Spending Account Over-the-Counter Health Care Reimbursement  (PDF, 284 KB)
Use this form to request reimbursement for over-the-counter products if your plan allows for over-the-counter reimbursements.

Before submitting a Dependent Care Reimbursement  (PDF, 234 KB) request, please read about dependent care expenses.

Before submitting a Limited FSA Reimbursement  (PDF, 329 KB) request, please read about our Limited FSA expenses.

Use this form to submit a request for reimbursement of Limited FSA over-the-counter medications and products  (PDF, 281 KB).

For more Flexible Spending Account forms, employer-specific forms, your account status, and payment information, visit your secure member website.

Aetna Group Life Insurance Forms

To file a claim or make a change, complete the forms and submit them to your employer or Aetna. If a section does not apply, or the information is not available, write "NA" in the space so we know you did not overlook the question.

Alaska Travel Benefits for groups 2-50

• Travel Benefits Flyer  (2 Pages)

Critical Illness and Accident

• Critical Illness claim form  (PDF, 351 KB)
• Accident claim form  (PDF, 283 KB)
• Critical Illness and Accident enrollment form  (PDF, 310 KB)
• Critical Illness claim form - New York  (PDF, 351 KB)
• Accident claim form - New York  (PDF, 323 KB)
• Critical Illness and Accident enrollment form - New York  (PDF, 316 KB)
• Critical Illness and Accident enrollment form - Florida  (PDF, 278 KB)

Massachusetts Residents' Tax Form

Are you a Massachusetts resident? 18 or older? Can you afford health insurance? If you answered yes to all three questions, you must have health coverage according to your state's laws. If you do not, you must pay a penalty through your tax return. Watch for Form MA 1099-HC in the mail.