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Request for Exclusion from Paper Shut-off Please use this form only if you have received a letter directly from Aetna stating that your paper explanation of benefits EOB will be shut off and you wish to continue receiving paper EOBs. THIS FORM IS ONLY EFFECTIVE FROM 3/1/2013 TO 12/31/2013. FORMS RECEIVED ON OR AFTER THE EXPIRATION DATE WILL NOT BE PROCESSED. Please complete one Request for Paper Shut-off Exclusion Form per TIN* All forms are subject to validation before restoring paper EOBs. This form cannot be used if your office is currently enrolled Electronic Remittance Advice ERA Indicates required fields within each section* Incomplete and/or illegible fields and signatures may delay the processing of your request. TIN Name Tax ID Number TIN Contact Name E-mail Address Telephone Number Fax Number Pay to/Billing National Provider Identifier NPI Primary Service Address Information Regarding Request for Exclusion We will only process exclusion forms for those providers who have received a letter directly from Aetna stating that their paper EOBs will be turned off in 2013. What is your reason for not turning off paper EOBs Concerns with account reconciliation Difficulty navigating secure website via NaviNet No internet access Other please explain Please Note If you are currently receiving ERAs you are not eligible to receive paper EOBs. By signing below I understand that I am instructing Aetna to send paper copies of explanation of benefits for this practice. Authorized health care professional name Signature Title Date Supervisor-level authorized health care professional name Form completed by Two signatures are required for authorization* Please FAX completed form to Aetna s Request for Paper Shut-off Exclusion fax number at 860-907-4761. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies Aetna. THIS FORM IS ONLY EFFECTIVE FROM 3/1/2013 TO 12/31/2013. FORMS RECEIVED ON OR AFTER THE EXPIRATION DATE WILL NOT BE PROCESSED. Please complete one Request for Paper Shut-off Exclusion Form per TIN* All forms are subject to validation before restoring paper EOBs. Please complete one Request for Paper Shut-off Exclusion Form per TIN* All forms are subject to validation before restoring paper EOBs. This form cannot be used if your office is currently enrolled Electronic Remittance Advice ERA Indicates required fields within each section* Incomplete and/or illegible fields and signatures may delay the processing of your request. This form cannot be used if your office is currently enrolled Electronic Remittance Advice ERA Indicates required fields within each section* Incomplete and/or illegible fields and signatures may delay the processing of your request. TIN Name Tax ID Number TIN Contact Name E-mail Address Telephone Number Fax Number Pay to/Billing National Provider Identifier NPI Primary Service Address Information Regarding Request for Exclusion We will only process exclusion forms for those providers who have received a letter directly from Aetna stating that their paper EOBs will be turned off in 2013.

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