Form Gc-7 (2-12)j - Aetna Medical Claim Form And Benefits Request Form Page 2
Download a blank fillable Form Gc-7 (2-12)j - Aetna Medical Claim Form And Benefits Request Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Gc-7 (2-12)j - Aetna Medical Claim Form And Benefits Request Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Refer to the back of your ID card
M edical Benefits Request
for claim mailing address
4 B
T O BE COMPLETED BY EMPLOYEE
0 B
1. Employer's Name
2. Policy/Group Number
5. Employee's Birthdate (MM/DD/YYYY)
3. Employee's Aetna ID Number
4. Employee's Name
6.
Active
Retired
7. Employee's Address (include ZIP Code)
Address is new
8. Employee's Daytime Telephone Number
(
)
Date of Retirement
11. Patient's Birthdate (MM/DD/YYYY)
9. Patient's Name
10. Patient's Aetna ID Number
12. Patient's Relationship to Employee
r
Self
Spouse
Child
Othe
13. Patient's Address (if different from employee)
14. Patient's Gender
Male
Female
15. Patient's Marital Status
16. Is patient employed?
17. Name & Address of Employer
Married
Single
No
Yes
18. Is claim related to an accident?
19. Is claim related to employment?
No
Yes
If Yes, date
time
am
pm
No
Yes
U
U
U
U
20. Are any family members expenses covered by another group health plan, group pre-payment plan (Blue
21. If Yes, list policy or contract holder, policy or contract number(s) and name/address of
Cross- Blue Shield, etc.), no fault auto insurance, Medicare or any federal, state or local government plan?
insurance company or administrator:
No
Yes
24. Member’s Birthdate (MM/DD/YYYY)
22. Member’s ID Number
23. Member’s Name
To all providers of health care:
25.
You are authorized to provide Aetna Life Insurance Company or one of its affiliated companies (“Aetna”), and any independent claim administrators and consulting health professionals
and utilization review organizations with whom Aetna has contracted, information concerning health care advice, treatment or supplies provided the patient (including that relating to
mental illness and/or AIDS/ARC/HIV). This information will be used to evaluate claims for benefits. Aetna may provide the employer named above with any benefit calculation used in
payment of this claim for the purpose of reviewing the experience and operation of the policy or contract. This authorization is valid for the term of the policy or contract under which a
claim has been submitted. I know that I have a right to receive a copy of this authorization upon request and agree that a photographic copy of this authorization is as valid as the original.
Patient's or Authorized Person's Signature
Date
U
26.
I authorize payment of medical benefits to the physician or supplier of service.
Patient's or Authorized Person's Signature
Date
U
T O BE COMPLETED BY PHYSICIAN OR SUPPLIER
1 B
27. Date of Illness (first symptom) or injury
28. Date first consulted you for this condition
29. If patient has had similar illness or injury, give dates
30. If an emergency check here
)
(accident) or pregnancy (LMP
emergency
31. Date patient able to return to work
32. Date of total disability
33. Date of partial disability
from
through
from
through
34. Name of referring physician (e.g., Public Health Agency)
35. For services related to hospitalization give hospitalization dates
admitted
discharged
36. Name & address of facility where services rendered (if other than home or office)
37. Diagnosis or nature of illness or injury (please indicate primary and secondary)
1.
2.
3.
4.
3 8. Procedures, Medical Services, Supplies Furnished
2 B
Date of
Place of
Procedure Code
Type of
Diagnosis
Administrative
Service
Service*
Identify**
Description of Service
Service
Charges
Days or Units
Code
Use Only
39. Physician's Name & Address (include ZIP Code)
40. Telephone Number
41. Enter the taxpayer identifying number to be used for 1099
(
)
reporting purposes. You are required under authority of law to
.
furnish your taxpayer identifying number
42. Patient Account Number
Total charge
$
43.
Amount paid
$
Balance due
$
44. Physician's or Supplier's Signature
45. National Provider Identifier
46. Date
* Place of Service Codes:
Type of Service Codes:
1 - (IH)
- Inpatient Hospital
8 - (SNF)
- Skilled Nursing Facility
1 - Medical Care
8 - Assistance at Surgery
2 - (OH)
- Outpatient Hospital
9 -
- Ambulance
2 - Surgery
9 - Other Medical Service
3 - (O)
- Office Visit
0 - (OL)
- Other Location
3 - Consultation
0 - Blood or Packed Red Cells
4 - (H)
- Patient Home
A - (IL)
- Independent Laboratory
A - Used DME
4 - Diagnostic X-Ray
5 -
- Day Care Facility (PSY)
B -
- Other Medical Surgical Facility
5 - Diagnostic Laboratory
M - Alternate Payment for Maintenance Dialysis
6 -
- Night Care Facility (PSY)
C - (RTC) - Residential Treatment Center
6 - Radiation Therapy
Y - Second Opinion on Elective Surgery
7 - (NH)
- Nursing Home
D - (STF)
- Specialized Treatment Facility
7 - Anesthesia
Z - Third Opinion on Elective Surgery
** Please Use Current Procedural Terminology Codes For Surgery
Please Use ICD•9•CM For Discharge Diagnosis
GC-7 (2-12) J
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business