Skip to main content
  • Contact us
  • Español

    • Working with us

    Claims

    Pharmacy

    Resources

    News and Insights

    Forms for health care professionals

    Want to enroll in ERA and EFT?

    Find all the forms you need

    Find forms and applications for health care professionals and patients, all in one place.

    Read Less

    safds

    It's easy to update a provider address, phone number, fax number or email address, or initiate an out-of-state move or a change in provider group.

     

    Update provider data

    Coordination of Benefits (PDF)

    Medicaid providers serving patients with Aetna Better Health insurance coverage must use the process indicated by the health plan they are serving.
     

    Find your plan

    For Part D prior authorization forms, see the Medicare Precertification section or the Medicare medical specialty drug and Part B step therapy precertification section.

     

    Standard Organization Determination Information Request Form (PDF)

     

    Hospital Discharge Appeal Notices

     

    Note: This page on the Centers for Medicare & Medicaid Services (CMS) site provides information about patient rights as a hospital inpatient and links to related forms.

     

    Part D prescription drug prior authorizations and exceptions

     

     

    Medicaid providers serving patients with Aetna Better Health insurance coverage must use the process indicated by the health plan they are serving.
     

    Find your plan

    Infertility Program Patient Registration form (PDF)

     

    Opioid addiction treatment: For Aetna commercial plans, there is no precertification required for buprenorphine products.

     

    Part D forms: Please see the Medicare section of this page.

    If you’re retiring, moving out of state or changing provider groups, simply use this form to let us know so we can terminate your existing agreement with us. If you’re moving or changing jobs, you can sign a new agreement for your new practice or location.

     

    Note: This form will also update your information on our online provider directory.

     

    Provider Termination request

     

    General forms

     

     

    Prescription drug forms

     

     

    Michigan providers: New electronic prior authorization law

     

    Michigan amended its current utilization review law. Starting June 1, 2023, all prior authorization requests need to be submitted electronically. It’s easy to work with us on Availity. It will help you stay compliant and you can take advantage of many other benefits. To register for Availity, you’ll need your physical address, billing address, tax ID, NPI and primary specialty. Already registered? Log in to Availity.

     

    The medical record exchange lets you submit medical records digitally. This helps meet measures to close gaps in care.

     

    Medical record exchange form

    For your patient to stay enrolled in a C-SNP plan, the CMS requires that we verify with you that your patient has been diagnosed with one or more chronic conditions. Use this form to send us that verification.

     

    C-SNP chronic condition attestation form (PDF)

    Legal notices

    Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

    Health benefits and health insurance plans contain exclusions and limitations.

    See all legal notices

    Also of interest: