Form Gc-7-42 - Medical Benefits Claim Instructions And Request Page 2
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1
2Mail to: Aetna Life Insurance Company
Medical Benefits Request
PO Box 981106
El Paso, TX 79998
TO BE COMPLETED BY MEMBER
1. School Name
2. Policy/Group Number
5. Member’s Birthdate (MM/DD/YYYY)
3. Member’s Aetna ID Number
4. Member’s Name
6. Member’s Address (include ZIP Code)
Address is new
7. Member’s Daytime Telephone
Number
(
)
10. Patient's Birthdate (MM/DD/YYYY)
8. Patient's Name
9. Patient's Aetna ID Number
11. Patient's Relationship to Member
Self
Spouse
Child
Other
12. Patient's Address (if different from member)
13. Patient's Gender
14. Full Time Student
15. Patient's Expected Graduation Date
16. Name of School and City
Male
Female
No
Yes
17. Patient's Marital Status
18. Is patient employed?
19. Name and Address of Employer
Married
Single
No
Yes
20. Is claim related to an accident?
21. Is claim related to employment?
No
Yes
If Yes, date
time
am
pm
No
Yes
22. Are any family members expenses covered by another group health plan, group pre-
23. If Yes, list policy or contract holder, policy or contract number(s) and name/address of
payment plan (Blue Cross- Blue Shield, etc.), no fault auto insurance, Medicare or any
insurance company or administrator:
federal, state or local government plan?
No
Yes
26. Member’s Birthdate (MM/DD/YYYY)
24. Member’s ID Number
25. Member’s Name
27. To all providers of health care:
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
28. I authorize payment of medical benefits to the physician or supplier of service.
Patient's or Authorized Person's Signature
Date
TO BE COMPLETED BY PHYSICIAN OR SUPPLIER
29. Date of Illness (first symptom) or injury
30. Date first consulted you for this condition 31. If patient has had similar illness or injury, give
32. If an emergency check here.
(accident) or pregnancy (LMP)
dates
emergency
33. Name of referring physician (e.g., Public Health Agency)
34. For services related to hospitalization give hospitalization dates
admitted
discharged
35. Name & address of facility where services rendered (if other than home or office)
36. Diagnosis or nature of illness or injury (please indicate primary and secondary)
1.
2.
3.
4.
37. Procedures, Medical Services, Supplies Furnished
Date of
Place of
Procedure Code
Type of
Days or
Service
Service*
Identify**
Description of Service
Service
Charges
Units
Diagnosis Code
38. Physician's Name & Address (include ZIP Code)
39. Telephone Number
40. 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.
41. Patient Account Number
42. Total charge $
Amount paid $
Balance due $
43. Physician's or Supplier's Signature
44. National Provider Identifier
45. 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
4 - Diagnostic X-Ray
A - Used DME
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 Code for Discharge Diagnosis
GC-7-42 (8-14)
Page 2 of 2
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