AlaskaCare Employee Forms

Appeal forms
Aetna Member Complaint and Appeal form [PDF 296K]
Moda Appeal form [PDF 31K]
OptumRx Member Complaint and Appeal form [PDF 72K]
Authorization for the Use and/or Disclosure of Protected Health Information (PHI) (ben043) [PDF 129K]
Authorizes the state AlaskaCare office to provide PHI to persons you indicate on this form
Automatic Withdrawal Form
Automatic Funds Withdrawal for COBRA and Direct Bill Premiums [PayFlex]
Claim forms
Dental claim form [PDF 2.0M]
Medical claim form [PDF 427K]
Health Flexible Spending Account (HFSA) claim form (PayFlex) [PDF 602K]
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)
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
  • HFSA Reimbursement
  • HFSA Over-the-Counter Claim
  • Direct Deposit Form for HFSA
  • Non-preferred provider
  • Pharmacy forms
  • Precertification
  • Other Health Insurance Verification
  • Request for Certification of Incapacitated Dependent


Record Release Form