Follow the steps to accurately complete your medical claim form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the Member section with your last name, first name, middle initial, and Member ID number.
3. Provide Patient Information if the claim is for a qualified dependent by entering their last name, first name, patient ID, date of birth, relationship, and gender.
4. If applicable, complete the Accident Information section by specifying the date of the accident or first symptoms of the illness. Indicate if the accident or illness is work-related, and provide details about the incident.
5. Complete the Medicare Information section only if the patient is eligible for Medicare, including the Medicare number and effective dates for Part A and Part B.
6. If you have other health insurance, fill out that section with the name of the policyholder, policy number, name of the insurance company, and their contact information.
7. In the Authorization/Release of Information section, sign and date to authorize the plan to obtain necessary information regarding the claim.
8. In the Assignment of Benefits section, again sign and date to authorize direct payment to the provider.
9. Once all sections are completed accurately, attach any original itemized bills and supporting documentation.
10. Finally, save your changes, download, print, or share the completed form as needed, ensuring you follow up with the provider or submit the claim as required.

Start completing your Aetna MHBP GC-16514 online to ensure timely processing of your medical claims.