Ffice Key Code 039 Complete this form when your disability absence goes beyond your plans waiting period. Ask your physician to complete the Attending Physician's Statement on the reverse side. 1. Employer Information Name Control Number 2342342344 Address (include ZIP Code) 2. Employee Information Social Security Number Name Birthdate (MM/DD/YYYY) ( Basic Income Has your employment terminated and/or are you currently on layoff? Daytime Telephone Number Address (include ZIP Cod.
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How to fill out the Aetna GC-1560-4 online
Completing the Aetna GC-1560-4 form online is essential for employees requesting benefits due to a disability absence. This guide provides clear, step-by-step instructions to help users fill out the form accurately and efficiently.
Follow the steps to successfully complete the Aetna GC-1560-4 form online.
- Click the ‘Get Form’ button to obtain the form and open it in the online editor.
- In the Employer Information section, enter your employer's name, control number, and address including ZIP code.
- In the Employee Information section, fill in your Social Security number, name, birthdate, and daytime telephone number. Provide your address and describe your job duties.
- Indicate if your employment has terminated, if you are on layoff, or if you are presently employed elsewhere. Specify your basic income in the weekly or monthly fields.
- In the Claim Information section, answer whether your absence is work-related or related to an accident. Provide the date and time of the incident if applicable, and describe the nature of your illness or injury.
- Enter your expected return to work date.
- In the Release section, sign and date the form to authorize information release to Aetna and relevant parties.
- Complete the Misrepresentation section by reading and understanding the penalties for providing false information.
- If necessary, move to the Attending Physician’s Statement section, where your physician will need to fill out information about your illness or injury.
- Review all provided information for accuracy, then save your changes, download the form, or print a copy for your records.
Complete your Aetna GC-1560-4 form online today to ensure a smooth processing of your disability claim.
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What is the payer ID for Aetna Medical?
Electronic claims submission Use Payer ID# 128CA when submitting claims to Aetna Better Page 2 Health of California.
What is the payer ID for Aetna medical claims?
Electronic claims submission Use Payer ID# 128CA when submitting claims to Aetna Better Page 2 Health of California.
What payer ID is 62118?
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What is the fax number for Aetna PO Box 14079 Lexington KY 40512?
You can also print and mail claims forms to Aetna Voluntary Plans, PO Box 14079, Lexington, KY 40512-4079, or Fax to 1-859-455-8650. Claims forms are available for download from the bottom of the screen when you access the member portal or call Member Services. Have questions?
What is the payer ID 60054?
Electronic claims Submit your dental claims and encounters electronically. Payer ID numbers are 60054 for Aetna claims and 68246 for Aetna encounters.
What is payer ID 68069?
Home State's Payer ID is 68069.
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