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Retiree Forms Index

Appeal forms
Aetna Member Complaint and Appeal form [PDF 296K]
Moda Appeal form [PDF 31K]
Authorization for the use and/or disclosure of Protected Health Information (PHI)
Authorization for the Use and/or Disclosure of PHI (ben043) [PDF 129K]
Automatic Withdrawal Form
Automatic Funds Withdrawal for COBRA and Direct Bill Premiums [PayFlex]
Claim forms
Prescription drug claim form [PDF 341K]
Dental claim form [PDF 2.0M]
Medical claim form [PDF 427K]
Vision claim form [PDF 597K]
Enrollment forms
Health Benefits Enrollment/Waiver for Retirees or Benefit Recipients Tier I (ben051)
Health Benefits Enrollment/Waiver for Retirees or Benefit Recipients Tier II and III (ben035)
Retiree Health Dependent Change (02-1854r)
Other Health Insurance Verification form [PDF 134K]
Authorizes other carriers to give Aetna information about any coverage they provide in relation to you and your dependents.
Provider Nomination form [PDF 37K]
Use this form to submit provider contact information to Aetna.
Student status verification [PDF 143K]
Verify your student dependents with Aetna so they may be covered.

Aetna form library

Use the above link for the following forms:

  • Health Benefits Claim form
  • Non-preferred provider
  • Other Health Insurance Verification
  • Pharmacy forms
  • Precertification
  • Travel authorization

HealthSmart Forms

For services rendered before January 1, 2014

For services rendered before January 1, 2014

Important note: HealthSmart no longer has an Alaskan mailing address. Please mail HealthSmart claim forms to:

  • HealthSmart Benefit Solutions
  • P.O. Box 3262
  • Charleston, WV 25332