Find forms for your Aetna® Medicare plan

Aetna Medicare forms to file a claim, appoint a representative and more

You can find help on this page to:

File a claim — to request reimbursement (ask us to pay you back)
Appoint someone else to talk to us about your health care
Appoint someone to act on your behalf
Order prescription drugs from CVS Caremark® Mail Service Pharmacy
File an appeal or complaint, or ask for other coverage
Disenroll from a plan

Ask us to pay you back	Choose form language (PDF)
For prescriptions – or – the shingles, tetanus, RSV or hepatitis vaccine Did you pay out of pocket for covered prescriptions or the vaccines listed below? Shingles Tetanus RSV Hepatitis Just download the prescription drug claim form. Then, follow the steps in the form to fill it out and send it back to us.	Prescription drug claim form English Español
For provider or service bills, wigs – or – the flu, pneumonia or COVID-19 vaccine Did you pay out of pocket for anything listed below? Medical, dental or vision services Wigs The flu, pneumonia or COVID-19 vaccine Aetna Medicare members Log in to file a reimbursement claim online Don’t want to file a claim online? Use the Medicare reimbursement claim form. No longer an Aetna Medicare member? You can still file a claim. Just download the reimbursement claim form. Then, follow the steps in the form to fill it out and send it back to us.	Medicare reimbursement claim form English Español
For eligible fitness services or items Did you pay for any covered fitness services or items out of pocket? Aetna Medicare members Log in to file a fitness claim online Don’t want to file a claim online? Use the fitness reimbursement claim form. No longer an Aetna Medicare member? You can still file a claim. Just download the fitness reimbursement form. Then, follow the steps in the form to fill it out and send it back to us.	Fitness reimbursement form English Español

Ask us to pay you back	For prescriptions – or – the shingles, tetanus, RSV or hepatitis vaccine Did you pay out of pocket for covered prescriptions or the vaccines listed below? Shingles Tetanus RSV Hepatitis Just download the prescription drug claim form. Then, follow the steps in the form to fill it out and send it back to us.
Choose form language (PDF)	Prescription drug claim form English Español
Ask us to pay you back	For provider or service bills, wigs – or – the flu, pneumonia or COVID-19 vaccine Did you pay out of pocket for anything listed below? Medical, dental or vision services Wigs The flu, pneumonia or COVID-19 vaccine Aetna Medicare members Log in to file a reimbursement claim online Don’t want to file a claim online? Use the Medicare reimbursement claim form. No longer an Aetna Medicare member? You can still file a claim. Just download the reimbursement claim form. Then, follow the steps in the form to fill it out and send it back to us.
Choose form language (PDF)	Medicare reimbursement claim form English Español
Ask us to pay you back	For eligible fitness services or items Did you pay for any covered fitness services or items out of pocket? Aetna Medicare members Log in to file a fitness claim online Don’t want to file a claim online? Use the fitness reimbursement claim form. No longer an Aetna Medicare member? You can still file a claim. Just download the fitness reimbursement form. Then, follow the steps in the form to fill it out and send it back to us.
Choose form language (PDF)	Fitness reimbursement form English Español

Give a personal caregiver permission to help with your care	Choose form language (PDF)
Let someone talk to us about your health or coverage You can always call us. But sometimes, you might want a family member, personal caregiver or someone else to talk to us for you. Just fill out the PHI form and they can speak to us anytime about your care. Aetna Medicare members Log in to request online Don’t want to request online? Use the PHI form. No longer an Aetna Medicare member? Just download the PHI form. Then, follow the steps in the form to fill it out and send it back to us.	Protected health information form English Español Chinese
Let someone make requests for you You can give a family member, personal caregiver or someone else permission to speak to us for you. They will be able to do things like: Get a coverage decision from us to see if we'll pay for a medication or a visit to your doctor or another provider. File an appeal so we can review and maybe change a coverage decision we made. File a grievance (complaint) about your doctor, a pharmacy or something else. If you want to have someone help with your Medicare questions, here's what to do: Download the appointment of representative form. Fill it out and choose someone to speak to us for you. This can be a family member, caregiver or someone else. Have them sign it. Send the signed form to us. This person is now called your "appointed representative." They have your permission to speak with us. The form is good for one year from the date you both sign it.	Appointment of Representative form English Español

Give a personal caregiver permission to help with your care

Choose form language (PDF)

Let someone talk to us about your health or coverage

You can always call us. But sometimes, you might want a family member, personal caregiver or someone else to talk to us for you. Just fill out the PHI form and they can speak to us anytime about your care.

Aetna Medicare members

Don’t want to request online? Use the PHI form.

No longer an Aetna Medicare member?

Just download the PHI form. Then, follow the steps in the form to fill it out and send it back to us.

Protected health information form

Let someone make requests for you

You can give a family member, personal caregiver or someone else permission to speak to us for you. They will be able to do things like:

Get a coverage decision from us to see if we'll pay for a medication or a visit to your doctor or another provider.
File an appeal so we can review and maybe change a coverage decision we made.
File a grievance (complaint) about your doctor, a pharmacy or something else.

If you want to have someone help with your Medicare questions, here's what to do:

Download the appointment of representative form.
Fill it out and choose someone to speak to us for you. This can be a family member, caregiver or someone else.
Have them sign it.
Send the signed form to us.

This person is now called your "appointed representative." They have your permission to speak with us. The form is good for one year from the date you both sign it.

Appointment of Representative form

Give a personal caregiver permission to help with your care	Let someone talk to us about your health or coverage You can always call us. But sometimes, you might want a family member, personal caregiver or someone else to talk to us for you. Just fill out the PHI form and they can speak to us anytime about your care. Aetna Medicare members Log in to request online Don’t want to request online? Use the PHI form. No longer an Aetna Medicare member? Just download the PHI form. Then, follow the steps in the form to fill it out and send it back to us.
Choose form language (PDF)	Protected health information form English Español Chinese
Give a personal caregiver permission to help with your care	Let someone make requests for you You can give a family member, personal caregiver or someone else permission to speak to us for you. They will be able to do things like: Get a coverage decision from us to see if we'll pay for a medication or a visit to your doctor or another provider. File an appeal so we can review and maybe change a coverage decision we made. File a grievance (complaint) about your doctor, a pharmacy or something else. If you want to have someone help with your Medicare questions, here's what to do: Download the appointment of representative form. Fill it out and choose someone to speak to us for you. This can be a family member, caregiver or someone else. Have them sign it. Send the signed form to us. This person is now called your "appointed representative." They have your permission to speak with us. The form is good for one year from the date you both sign it.
Choose form language (PDF)	Appointment of Representative form English Español

Order prescription drugs by mail	Choose PDF language
Use CVS Caremark® Mail Service Pharmacy Check to see if your prescription drugs can be ordered with CVS Caremark® Mail Service Pharmacy. If they are, you can use this form to place an order. Just follow the steps in the form to fill it out and send it back to us.	Choose form language (PDF) English Español

Order prescription drugs by mail	Use CVS Caremark® Mail Service Pharmacy Check to see if your prescription drugs can be ordered with CVS Caremark® Mail Service Pharmacy. If they are, you can use this form to place an order. Just follow the steps in the form to fill it out and send it back to us.
Choose PDF language	Choose form language (PDF) English Español

File a coverage decision, appeal or grievance (complaint)

Have a question or concern about your plan coverage or care? Our Member Services team can help. Just call the number on your Aetna member ID card.

Learn more about coverage decisions, appeals and grievances

File a coverage decision, appeal or grievance (complaint)

Have a question or concern about your plan coverage or care? Our Member Services team can help. Just call the number on your Aetna member ID card.

Learn more about coverage decisions, appeals and grievances

Leave or cancel your plan (disenrollment)
For Medicare Advantage (Part C) or Medicare Advantage Prescription Drug plans (Parts C + D) Do you want to leave your current plan and not join another one? You can call us at the number on your member ID card for help. Or find the Member Services number for your plan online. We’ll let you know your options. Like joining a plan, there are only certain times when you can disenroll.* You can download this form. Just fill out the steps in the form to fill it out and send it back to us. How to send us your form If there are more than 10 days before the end of the month: You should mail your form to: Aetna PO Box 14088 Lexington, KY 40512 If there are 10 days or fewer left until the end of the month: You should fax your form to 1-866-756-5514. Important note: Do you have a Medicare Advantage plan that includes prescription drug coverage (Parts C and D)? If you switch from that plan to a Medicare prescription drug plan (Part D only), this will disenroll you from your Medicare Advantage plan. You’ll return to Original Medicare if you switch from a Medicare Advantage plan (with drug coverage) to a Medicare prescription drug plan.	Medicare Advantage Plan Disenrollment Form English Español
For Prescription Drug plans (PDPs) Do you want to leave or switch your Medicare Part D plan? Find out what your options are. Learn all about how and when to disenroll from your PDP

Leave or cancel your plan (disenrollment)

For Medicare Advantage (Part C) or Medicare Advantage Prescription Drug plans (Parts C + D)

Do you want to leave your current plan and not join another one? You can call us at the number on your member ID card for help. Or find the Member Services number for your plan online.

We’ll let you know your options. Like joining a plan, there are only certain times when you can disenroll.* You can download this form. Just fill out the steps in the form to fill it out and send it back to us.

How to send us your form

If there are more than 10 days before the end of the month:

You should mail your form to:

Aetna
PO Box 14088
Lexington, KY 40512

If there are 10 days or fewer left until the end of the month:

You should fax your form to 1-866-756-5514.

Important note: Do you have a Medicare Advantage plan that includes prescription drug coverage (Parts C and D)? If you switch from that plan to a Medicare prescription drug plan (Part D only), this will disenroll you from your Medicare Advantage plan. You’ll return to Original Medicare if you switch from a Medicare Advantage plan (with drug coverage) to a Medicare prescription drug plan.

Medicare Advantage Plan Disenrollment Form

For Prescription Drug plans (PDPs)

Do you want to leave or switch your Medicare Part D plan? Find out what your options are.

Learn all about how and when to disenroll from your PDP

Leave or cancel your plan (disenrollment)	For Medicare Advantage (Part C) or Medicare Advantage Prescription Drug plans (Parts C + D) Do you want to leave your current plan and not join another one? You can call us at the number on your member ID card for help. Or find the Member Services number for your plan online. We’ll let you know your options. Like joining a plan, there are only certain times when you can disenroll.* You can download this form. Just fill out the steps in the form to fill it out and send it back to us. How to send us your form If there are more than 10 days before the end of the month: You should mail your form to: Aetna PO Box 14088 Lexington, KY 40512 If there are 10 days or fewer left until the end of the month: You should fax your form to 1-866-756-5514. Important note: Do you have a Medicare Advantage plan that includes prescription drug coverage (Parts C and D)? If you switch from that plan to a Medicare prescription drug plan (Part D only), this will disenroll you from your Medicare Advantage plan. You’ll return to Original Medicare if you switch from a Medicare Advantage plan (with drug coverage) to a Medicare prescription drug plan.
	Medicare Advantage Plan Disenrollment Form English Español
Leave or cancel your plan (disenrollment)	For Prescription Drug plans (PDPs) Do you want to leave or switch your Medicare Part D plan? Find out what your options are. Learn all about how and when to disenroll from your PDP

Disclaimers

CVS Caremark® Mail Service Pharmacy and Aetna® are part of the CVS Health® family of companies.

You may continue to use CVS® pharmacies (retail, CVS Caremark® Mail Service Pharmacy, CVS Specialty® and Omnicare® long-term pharmacies) in the State of Arkansas, unless a court takes action on Arkansas laws that were scheduled to take effect on January 1, 2026, but have been enjoined by the court.

Find forms for your Aetna® Medicare plan

Aetna Medicare forms to file a claim, appoint a representative and more

Ask us to pay you back

Choose form language (PDF)

For prescriptions – or – the shingles, tetanus, RSV or hepatitis vaccine

For provider or service bills, wigs – or – the flu, pneumonia or COVID-19 vaccine

For eligible fitness services or items

Ask us to pay you back

For prescriptions – or – the shingles, tetanus, RSV or hepatitis vaccine

Choose form language (PDF)

Ask us to pay you back

For provider or service bills, wigs – or – the flu, pneumonia or COVID-19 vaccine

Choose form language (PDF)

Ask us to pay you back

For eligible fitness services or items

Choose form language (PDF)

Give a personal caregiver permission to help with your care

Choose form language (PDF)

Let someone talk to us about your health or coverage

Let someone make requests for you

Give a personal caregiver permission to help with your care

Let someone talk to us about your health or coverage

Choose form language (PDF)

Give a personal caregiver permission to help with your care

Let someone make requests for you

Choose form language (PDF)

Order prescription drugs by mail

Choose PDF language

Use CVS Caremark® Mail Service Pharmacy

Choose form language (PDF)

Order prescription drugs by mail

Use CVS Caremark® Mail Service Pharmacy

Choose PDF language

Choose form language (PDF)

File a coverage decision, appeal or grievance (complaint)

File a coverage decision, appeal or grievance (complaint)

Leave or cancel your plan (disenrollment)

For Medicare Advantage (Part C) or Medicare Advantage Prescription Drug plans (Parts C + D)

Read more below

Medicare Advantage Plan Disenrollment Form

For Prescription Drug plans (PDPs)

Leave or cancel your plan (disenrollment)

For Medicare Advantage (Part C) or Medicare Advantage Prescription Drug plans (Parts C + D)

Read more below

Medicare Advantage Plan Disenrollment Form

Leave or cancel your plan (disenrollment)

For Prescription Drug plans (PDPs)

Disclaimers