Form Gr-68069-9 - Claim Form - Aetna Global Benefits
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2Claim Form
®
A etna Global Benefits
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Please also complete Page 2 of this form.
Medical*
Pharmacy*
Dental*
Vision*
* Refer to your plan documents to verify the coverage(s) that are available through your Plan.
1 B
Please mail or fax completed Claim Form with itemized bills and receipts. A separate Claim Form is needed for each family
member. Please tape small receipts on a full size sheet of paper.
Aetna Global Benefits/Aetna
Telephone: +1-877-677-7470 (Toll Free, outside the USA, via AT&T + access)
P.O. Box 981543
+1-813-775-0196 (Collect outside the USA)
El Paso, TX 79998-1543
Facsimile: +1-877-287-1938 (Toll Free, outside the USA, via AT&T + access)
USA
+1-813-775-0195 (Direct, outside the USA, via AT&T + access)
E-mail:
A
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1. Employee Information
Employer Name/Group Number
G eneral Electric / 724874
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Employee's Name
U
(First Name, Middle Initial, Last Name/Surname as displayed on Aetna ID Card)
Identification Number (Use the number specified on your AETNA ID card)
Employee's Birthdate (mm/dd/yyyy)
/
/
Gender
Male
Female
Street
U
City
State/Province
U
U
U
Country
Postal/Zip Code
U
U
U
Employee's Telephone Number (Include Country Code)
U
Employee's Primary E-Mail Address
U
( Email addresses are strongly encouraged in the event additional information is needed to process your claim.)
U
2. Patient Information
Patient's Name (First Name, Middle Initial, Last Name/Surname)
U
Relationship:
Self
Spouse
Child
Other
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Patient's Birthdate (mm/dd/yyyy)
/
/
Gender
Male
Female
Report cards, tuition statements & other forms of school attendance verification may be required once per school year, if your plan includes
eligibility guidelines that require school attendance as a condition of coverage for dependents in excess of a specific age. See your plan
documents for additional details.
3.
Summary of Medical, Pharmacy, Dental, and Vision Services
(Please include diagnosis or reason for treatment for each service
received.)
• For prosthetic services (crowns, bridges or dentures) the following information must be supplied:
• For periodontal services (gum disease), member must submit
• The x-rays. (If x-rays are not available, provide the dentist's
narrative report.)
x-rays and periodontal charting.
• For all dental claims (other than preventive services, e.g. oral
• For orthodontic services, the following information must be
exams, x-rays, cleanings, fluoride, etc), complete the Dentist's
provided: date appliance placed, number of months of
treatment, months of treatment remaining.
Statement (GC-14423) and attach to this claim form. Be sure to
• For services related to an accidental injury, the patient must
identify the related tooth number for all dental procedures and
include extraction dates or original placement date and reason for
always include pre-treatment x-rays and details of the accident.
replacement of denture or bridge replacement.
• If the claim is for a bridge or denture, we will need a chart of all
other missing teeth in the mouth, and their dates of extraction.
Description of Service/
Provider's (physician, clinic, hospital,
Name of Medication/
Drug/Device
Dates of
pharmacy) Name and Address
City/State/
Service
(If the Provider’s name and address is
(If hospital, indicate
Diagnosis
Province/Country
Currency
Total
(mm/dd/yyyy)
on receipts, write “see receipts”)
inpatient or outpatient)
(Reason for visit)
of Claim
of Claim
Charge
4. Claim Information
If Yes is answered to either question below, c and d in this section must be completed.
a.
Is the claim related to a work related accident or condition?
Yes
No
b.
Is the claim related to an accidental injury?
Yes
No
c.
Accident Date (mm/dd/yyyy)
/
/
Time
AM
PM
U
U
d.
Description of Accident (How and Where)
U
U
Please Retain A Copy For Your Records
GR-68069-9 GE (10-09)
Coverage underwritten by Aetna Life Insurance Company and Aetna Life & Casualty (Bermuda) Ltd.
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