Aetna Medical Claim Form 2 - Free Download
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Claim Form
Medical* Dental* Vision*
* Refer to your plan documents to verify the coverage(s) that
are available through your Plan.
Aetna Global Benefits®
Please also complete Page 2 of this form.
Please mail or fax completed Claim Form with itemized bills and receipts. A separate claim form is needed for each
family member. Please tape small receipts on 8.5 x 11 paper.
Aetna Global Benefits
P.O. Box 30258
Tampa, FL 33630-3258
USA
OR
Aetna Global Benefits
4630 Woodlands Corporate Blvd.
Tampa, FL 33614
USA
Telephone: (800) 231-7729 (outside the USA, via AT&T + access)
(813) 775-0190 (direct or collect outside the USA)
Facsimile: (800) 475-8751 (outside the USA, via AT&T + access)
(813) 775-0625 (inside the USA)
E-mail: agbservice@aetna.com
1. Employee Information
Employer Name/Group Number
Employee's Name
(First Name, Middle Initial, Last Name/Surname as displayed on Aetna ID Card)
Identification Number (Use the number specified on your AETNA ID card)
Employee's Birthdate (mm/dd/yyyy)
/ /
Gender Male Female
City
State/Province
Country
Employee's Telephone Number (Include Country Code)
Employee's Primary E-Mail Address
(Email addresses are strongly encouraged in the event additional information is needed to process your claim.)
2. Patient Information
Patient's Name (First Name, Middle Initial, Last Name/Surname)
Relationship:
Self Spouse Child Other
Patient's Birthdate (mm/dd/yyyy)
/ /
Gender Male Female
If the patient is over the age of 19 and attending school, you must provide verification, such as report cards, tuition statements, etc., once per school year.
3. Summary of Medical, Dental, and Vision Services (Please include diagnosis or reason for treatment for each service received.)
• For Prosthetic services (crowns, bridges or dentures) the following information must be supplied:
• The x-rays. (If x-rays are not available, provide the dentist's narrative
report.)
• For dentures and bridges: the date or dates of extraction of teeth
involved. If it is a denture or bridge replacement, include the date of
prior placement and reason for replacement.
• If the claim is for a bridge or denture, we will need a chart of all other
missing teeth in the mouth, and their dates of extraction.
• For periodontal services (gum disease), member must submit x-rays
and periodontal charting.
• For orthodontic services, the following information must be
provided: date appliance placed, number of months of treatment,
months of treatment remaining.
• For services related to an accidental injury, the patient must always
include pre-treatment x-rays and details of the accident.
Dates of
Service
(mm/dd/yyyy)
Provider's (physician, clinic, hospital)
Name and Address
(If the Provider’s name and address is
on receipts, write “see receipts”)
Description
of Service
(If hospital, indicate
inpatient or outpatient)
Diagnosis
(Reason for visit)
City/State/
Province/Country
of Claim
Currency
of Claim
Total
Charge
4. Claim Information
If Yes is answered to either question below, c and d in this section must be completed.
a. Is the claim related to a work related accident or condition
Yes No
b. Is the claim related to an accidental injury
Yes No
c. Accident Date (mm/dd/yyyy)
/ / Time AM PM
d. Description of Accident (How and Where)
Please Retain A Copy For Your Records
GR-68069 (6-05) A-POD Coverage underwritten by Aetna Life Insurance Company and Aetna Life & Casualty (Bermuda) Ltd. Page 1 of 2
