Retiree Forms Index

Appeal forms
Aetna Member Complaint and Appeal form [PDF 296K]
Moda Appeal form [PDF 31K]
OptumRx Member Complaint and Appeal form [68.4K]
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 (Aetna) [PDF 1.2M]
(for prescriptions filled before 1/1/19)
Prescription drug claim form (OptumRx) [PDF 302K]
(for prescriptions filled on or after 1/1/19)
Dental claim form [PDF 2.0M]
Medical claim form [PDF 427K]
Vision claim form [PDF 597K]
Enrollment forms
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


Record Release Form