Find the 2016 forms and documents you need
Not all forms may apply to your coverage and benefits. To find forms customized for your benefits, log in to your secure member account.
If you have questions about which forms are meant for your use, call the toll-free number on the back of your member ID card.
Medical, dental & vision claim forms
Health care professionals in our network should file claims for you. (Some out-of-network health care professionals also may 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 Aetna network, and you need to submit a claim, please complete and mail one of the forms below to the address on your ID card.
Authorization to release information
Use this form to give us permission to share information about you (or a dependent) with another person or company. You can also choose the types of coverage for which the permission applies.
- Authorization to Release Protected Health Information (English)
- Authorization to Release Protected Health Information (Spanish)
- Money2 for Health Authorization for the Release of PHI form (English)
- Money2 for Health Authorization for the Release of PHI form (Spanish)
Use this form to remove permission previously given to share information about you (or a dependent) with another person or company.
Pharmacy mail-order & claims
Spending account reimbursement (FSA,HSA)
Critical illness & accident forms
Massachusetts residents: health insurance mandate
Are you a Massachusetts resident? Are you 18 or older? Can you afford health insurance? If you answered yes to all three questions, you must have health coverage according to Massachusetts laws. If you do not, you must pay a penalty through your tax return.
CALIFORNIA GRIEVANCE FORMS
Aetna Health of California HMO has procedures for Members to use if they are dissatisfied with a decision that the HMO has made or with the operation of the HMO.