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Get Aetna GR-68192 2012

Member Complaint and Appeal Form NOTE Completion of this form is voluntary. To obtain a review you or your authorized representative may also call our Member Services Department using the telephone number displayed on the member ID card or submit a request in writing to the address listed at the end of your Explanation of Benefits EOB or other correspondence received from Aetna. Please provide the following information for the primary Insured/Member. This information may be found on the front of your ID card. Today s Date Member s ID Number Member s Group Number Optional Plan Type Medical Member s First Name Member s Last Name Dental Member s Birthdate MM/DD/YYYY First Name Last Name Birthdate MM/DD/YYYY Relationship to person requesting the appeal Self Spouse Child Other Note If your selection is spouse child 18 years of age or older or other please complete and include the attached U To help Aetna review and respond to your request please provide the following information. Claim ID Number Optional Reference Number Optional Service Date Optional Explanation of Your Request Please use additional pages if necessary. Note When submitting this form with your request please include You may mail your request to Aetna PO Box 14463 Lexington KY 40512 Or use our National Fax Number - Bills and/or correspondence for these services - Any other helpful information. 859-425-3379 CRTM GR-68192 10-12 R-POD C. This information may be found on the front of your ID card. Today s Date Member s ID Number Member s Group Number Optional Plan Type Medical Member s First Name Member s Last Name Dental Member s Birthdate MM/DD/YYYY First Name Last Name Birthdate MM/DD/YYYY Relationship to person requesting the appeal Self Spouse Child Other Note If your selection is spouse child 18 years of age or older or other please complete and include the attached U To help Aetna review and respond to your request please provide the following information* Claim ID Number Optional Reference Number Optional Service Date Optional Explanation of Your Request Please use additional pages if necessary. Note When submitting this form with your request please include You may mail your request to Aetna PO Box 14463 Lexington KY 40512 Or use our National Fax Number - Bills and/or correspondence for these services - Any other helpful information* 859-425-3379 CRTM GR-68192 10-12 R-POD C. .

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