Get Claim Form Page - Benefits Online

This guide provides clear and comprehensive instructions on how to accurately fill out the Claim Form Page for Benefits Online. By following these steps, you will ensure a smooth submission process for your claims.

Follow the steps to successfully complete your claim form.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Begin by filling in the employee information. Provide the employer name or group number, the employee's full name as shown on their Aetna ID card, and their identification number from the card.
3. Complete the patient information section. Fill out the patient's name, relationship to the employee (self, spouse, child, or other), and the patient's birthdate in the same format (mm/dd/yyyy). Select the patient's gender.
4. In the summary of medical, pharmacy, dental, and vision services section, provide detailed information for each service received. Include dates of service, the provider's name and address, description of the service or medication, diagnosis, and the total charge for each item.
5. Answer the claim information questions. Indicate if the claim is related to a work-related accident or an accidental injury. If 'Yes,' provide additional details including the date and description of the accident.
6. Complete the summary of reimbursement section. Decide your reimbursement method and currency type. If opting for Funds Transfer, fill out the relevant bank information in section 6.
7. If applicable, indicate whether any family members’ expenses are covered by another health plan. Provide the necessary details if there are additional coverage plans.
8. Sign and date the authorization, confirming your agreement with the terms outlined in the form. Ensure you retain a copy of the completed form for your records.

Complete your documents online now to ensure a timely processing of your claims.