Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online document editor.
2. Enter your Aetna ID number in the designated field to ensure correct identification in the system.
3. Fill in the Rx group number as provided by your insurance provider.
4. Input your full name, including first, middle, and last names, to match your identification with your policy.
5. Provide your birthdate in the format MM/DD/YYYY, ensuring accurate age verification.
6. Complete your address by entering your street, city, state, and ZIP code to ensure proper correspondence.
7. Input your telephone number in the designated area.
8. Indicate the date of filling out this form.
9. For each prescription, fill in the patient's last name, first name, and middle initial, followed by their birthdate.
10. Select the appropriate gender option for the patient.
11. Respond to whether your expenses are covered by another health plan; if yes, provide relevant policy details.
12. Indicate the reason for manually filing claims, such as Coordination of Benefits or Compound Drug, and provide the required additional information.
13. Attach all original pharmacy receipts for reimbursement and ensure they meet the required conditions.
14. Review all filled sections of the form for accuracy and completeness before final submission.
15. Save any changes made to the form, and utilize options to download, print, or share as needed after filling is complete.

Start completing your documents online today for a streamlined experience.