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