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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)

How to enroll in an Aetna Medicare plan

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