Skip to main content

Find a health insurance form

Not all forms may apply to your coverage and benefits. To find forms customized for your benefits, log in to your 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.  


Find the forms and documents you need

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 (English - PDF)

 

Medical Claim Form (Spanish - PDF)

 

Dental Claim Form (English - PDF)

 

Dental Claim Form (Spanish - PDF)

 

Vision Claim Form for vision benefits within a medical plan (PDF)

 

Vision Claim Form for vision benefits through the Aetna Vision Preferred plan (PDF)

 

Spanish vision claim form for vision benefits through the Aetna Vision Preferred Plan (PDF)

 

Complaint and Appeal Form (PDF)

  

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 - PDF)

 

Authorization to Release Protected Health Information (Spanish - PDF)

 

Use this form to remove permission previously given to share information about you (or a dependent) with another person or company.

 

Revocation of Authorization (English - PDF)

 

Revocation of Authorization (Spanish - PDF)

Instructions for ordering a blood glucose monitor Diabetic Supply Order Form (PDF)

 

To refill a medication through mail-order delivery, log in to your 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 for CVS Caremark Mail Service Pharmacy (English - PDF)

 

Prescription mail-order delivery form for CVS Caremark Mail Service Pharmacy (Spanish - PDF)

 

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.

 

Prescription drug claim form (English - PDF)

 

Prescription drug claim form (Spanish - PDF)

If you have any of these PayFlex® accounts, you can get your forms or request reimbursement online.

 

  • Health care flexible spending account (FSA)
  • Dependent care FSA
  • Limited purpose FSA
  • Health savings account (HSA)
  • Health reimbursement arrangement (HRA)
  • Retiree reimbursement account (RRA)

 

Here’s what you need to do

 

  • Log in to aetna.com
  • Select Spending/Savings Accounts with PayFlex. This takes to you to the PayFlex member website.
  • From your account dashboard, you can file a claim or request funds. Or you can go to Help & Support to download forms from the Resource Center.

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.

 

Read more about this requirement

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

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.

 

The Internal Revenue Service (IRS) recently issued a Notice related to information reporting requirements that were added by the Affordable Care Act (ACA). Because the tax penalty for filing to meet the “individual mandate” has now been reduced by Congress to zero, the IRS indicated in its Notice that “an individual does not need the information on Form 1095-B in order to compute his or her federal tax liability or file an income tax return with the Service.” As a result, Aetna will not be mailing Form 1095-B for the reporting tax year. For those that previously received their Form 1095-B in the mail, you can receive a copy of your Form 1095-B by going out to the Aetna Member Website in the “Message Center” under the “Letters and Communications” tab or by sending us a request at Aetna PO BOX 981206, El Paso, TX 79998-1206. We will continue to provide the 1095-B form to members who live in the States that have passed their own individual mandate i.e. New Jersey, Washington, D.C., Vermont, Rhode Island, and California.

 

If you have an interest in receiving this form, please follow the steps above, email us at AetnaMemberServices@aetna.com or call1-855-531-6837with any questions.