Get a Form

Print a prescription drug claim form

Print a prescription drug claim form (Spanish)

Print and complete this form for medical, dental, vision, hearing, or vaccine reimbursement.

• Fill out this form if you were billed directly by a provider and would like to request reimbursement for medical care (includes dental, vision, hearing and vaccines). Don’t use this form for prescription drug reimbursement.

Medical, Dental, Hearing, Vision & Vaccine Reimbursement Form

Medical, Dental, Hearing, Vision & Vaccine Reimbursement Form (Spanish)

No printer?  No problem.  Learn what to send us for reimbursement.

Instructions if you can’t print the medical reimbursement form

Instructions if you can’t print the medical reimbursement form (Spanish)

Let someone else talk to us about your health or coverage

• One-time only: You can give us your permission by phone. We can speak with that person during that call.
• On an ongoing basis: You may want someone to speak with us more often. If so, you’ll need to mail us an Authorization for Release of Protected Health Information (PHI) form. It lets this person access your personal health information. They can also speak with us on your behalf.

Open and print the PHI form

Open and print the PHI form (Spanish)

Let someone file a grievance (complaint), ask for coverage or make an appeal for you

• You can choose someone to do all of the above. This person is your appointed representative. An appointment is good for one year from the date that you and your representative sign an Appointment of Representative form.
• Fill out this form below and mail it to us. Any time your representative makes a request for you, they should send us a signed copy. You'll leave Aetna Medicare and go to the CMS website if you link to the form.

Appointment of Representative CMS Form

Appointment of Representative CMS Form (Spanish)

Medication Order Form for CVS Caremark^® Mail Service Pharmacy

Medication Order Form for CVS Caremark Mail Service Pharmacy (Spanish)

Medication Action Plan

Medication Action Plan (Spanish)

Personal Medication List

Personal Medication List (Spanish)

Learn more about requesting an exception or filing a grievance or appeal:

Access forms and learn what steps to take

Call us at the number on your ID card if you want to leave or cancel your current plan and not join another one. Or, select your current plan and find its specific phone number on our Contact Member Services page.

We’ll let you know your options. Like joining a plan, there are only certain times when you can disenroll.¹ You may also download, complete and submit a disenrollment form — use the PDF link for your plan below to print its form:

Medicare Advantage Plan Disenrollment Form

Medicare Advantage Plan Disenrollment Form – Spanish

Prescription Drug Plan Disenrollment Form (Change from MAPD to MA)

Prescription Drug Plan Disenrollment Form (Change from MAPD to MA) – Spanish

Please complete the relevant form and mail it to:

Aetna
PO Box 14088
Lexington, KY 40512

Timing Considerations: If there are 10 days or fewer left until the end of the month, please fax the form to 1-888-665-6296. If you leave us during the annual election period, your last day of coverage is usually Dec. 31.

Important Note: If you change from a Medicare Advantage plan that includes prescription drug coverage to a Medicare prescription drug plan, 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.

If you receive care at a VA center, privacy laws mean you must let the VA know that it’s OK to share your treatment information with Aetna. Please fill out and return this form so that we can better coordinate our outreach. This helps us make sure you get the care you need and don’t get unnecessary communications.

Mail to:
 

Aetna Medicare
9401 Indian Creek Parkway
Suite 3100
Overland Park, KS 66210

Attn: Angie England
 

Download the VA permission form