Aetna Medical Benefits Request Form

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Please complete this form if you are interested in joining the aetna s network.

Aetna medical benefits request form. If you wish to have your benefits for this claim paid directly to your physician or supplier sign block twenty eight 28. Request a hard copy. Employees daytime telephone number date of retirement 9.

You fill out this section. Employees birthdate mm dd yyyy 6. Medical benefits request refer to your digital id card for claim mailing address note.

Request a hard copy through the aetna service center that services your employer. Employees aetna id number 4. Instructions are on the back of this form.

Include the reason for the change and the affected service address es. This information can be obtained from the claim form. Aetna medical benefits request to be completed by employee 1.

Employees address include zip code d address is new 8. Submit form send the completed benefit request form and appropriate documentation to theaetna service center that services your employer. If you have submitted a request for benefits to another plan including medicare attach a copy of the bills you submitted to the other plan and the explanation of benefits you received from the other plan.

My aetna id number. If you already work with us and need to update your tax id tin do not use this form. You only have to fill out this form if your doctor or other health care professional isn t filing the claim for you.

Instead fax us a letter and your new w 9 form to 859 455 8650.

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