Enrollee Information

Enrollee name

*Enrollee's First Name:

Middle Initial:

Last Name:

Enrollee's data of birth

*Date of Birth:

Month:

Day:

Year:

*Enrollee's Address:

Street 2:

* City: *State:

* Zip Code:

*Enrollee Plan ID Number:

(See your ID card)

Email Address:

* Confirm Email Address:

(mandatory if email entered)

* Enrollee Phone: Enrollee Phone Area Code - Enrollee Phone Prefix - Enrollee Phone Suffix

Yes

Complete the following Requested By section ONLY if the person making this request

is not the enrollee.

Requested By

Requester Name

*Requestor's First Name:

Last Name:

*Requestor's Address:

*City: *State:

* Zip Code:

*Requestor's Phone: Requestor Phone Area Code - Requestor Phone Prefix - Requestor Phone Suffix

Requestor's Email

Address:

* Requestor's Confirmation Email:

(mandatory if email

entered)

*Requestor's Relationship to
Enrollee:

Note about representatives: If you want another individual (such as a family member, your doctor or friend) to request an appeal for you, that individual must be your representative. Upon receipt of this online form, we will contact you if the form was submitted by anyone other than you. Use Authorization of Representation For CMS-1696 or equivalent to appoint a representative

Payment Request (Services have already been rendered ):

*Did you receive an Explanation of Benefits and/or was service rendered? Yes No

*Provider who

Performed the Service:

*Date service was rendered Month: Day: Year:

*Amount being Appealed

Just use the authorization link if service was not rendered

Comments

please explain your reasons for appealing.

Signature of Requestor

* Please provide your signature by typing your name in the box:

Date

*Please check the box to verify that you are the individual completing this form.

Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Enrollment in our plans depend on contract renewal. See Evidence of Coverage for a complete description of plan benefits. Plan features and availability may vary by service area.

Please review your information carefully and make

any changes before sending.

Click the Submit button only once.

Form may require 30+ seconds to process.

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