Retiree Forms Index
- Aetna Member Complaint and Appeal form [PDF 296K]
- Completion of this form is voluntary.
- 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.
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
- Benefits claim form [PDF 342K]
- Prescription reimbursement form [PDF 249K]
- Request for certification of incapacitated dependent [PDF 89K]
- Student status verification [PDF 75K]