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 1.2M]
- 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 163K]
- 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