Find the 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.
- Medical Claim Form
- Dental Claim Form (English)
- Dental Claim Form (Spanish)
- Vision Claim Form
- Complaint and Appeal Form
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
To refill a medication through mail-order delivery, log in to your secure member account. If you have a new prescription and want to start mail-order delivery, fill out the form below and send it to us with your prescription.
Prescription mail-order delivery form
In case of an emergency, or when traveling, you may need to use a pharmacy that is not in our network. In that case, complete the claim form and mail it to the address on the claim form.
Spending account reimbursement (FSA, HSA)
PayFlex®Forms
Find the reimbursement forms and other forms related to your flexible spending or health spending account on PayFlex.®
Health care and/or dependent care reimbursement form
Aetna FSAs
Health care reimbursement form
Limited FSA health care reimbursement form
Limited FSA over-the-counter reimbursement form
Dependent care reimbursement form
Over-the-counter reimbursement form
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.
View more information on how California members can get help
Tax Form 1095
If you had health insurance coverage at any time in 2016, you will receive a tax form 1095. There are three versions:
1095-A comes from the federal government Federal Exchange Marketplace or state-based Exchange Marketplace.
1095-B comes from your insurance company.
1095-C comes from your employer.
People generally receive only one version, though some may get both a 1095-B and a 1095-C.
See our information about what this form is for, what to do with it, and how to get one if yours is lost or misplaced.
