Form Gc-7 (2-12)j - Aetna Medical Claim Form And Benefits Request Form

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M edical Benefits – Claim Instructions

5 B

Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any

materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects

such person to criminal and civil penalties.

Attention Arkansas, District of Columbia, Rhode Island and West Virginia Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or

knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention California Residents: For your

protection California law requires notice of the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a

crime and may be subject to fines and confinement in state prison. Attention Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to

an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any

insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding

or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the

department of regulatory agencies. Attention Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an

application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Attention Kansas and Missouri Residents: Any person who knowingly and

with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or

conceals, for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Kentucky Residents: Any person who knowingly and with

intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information

concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Attention Louisiana Residents: Any person who knowingly presents a false or fraudulent claim

for payment of a loss or benefit or knowingly presents false information in an application is guilty of a crime and may be subject to fines and confinement in prison. Attention Maine and

Tennessee Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may

include imprisonment, fines, or denial of insurance benefits. Attention Maryland Residents: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a

loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention

New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy or knowingly files a statement of claim containing any false or

misleading information is subject to criminal and civil penalties. Attention New York Residents: Any person who knowingly and with intent to defraud any insurance company or other

person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material

thereto, commits a fraudulent insurance act, which is a crime, and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.

Attention North Carolina Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or

statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,

which may be a crime and subjects such person to criminal and civil penalties. Attention Ohio Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud

against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Attention Oklahoma Residents: WARNING: Any person

who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is

guilty of a felony. Attention Oregon Residents: Any person who with intent to injure, defraud, or deceive any insurance company or other person submits an enrollment form for insurance

or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may have violated state law.

Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim

containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime

and subjects such person to criminal and civil penalties. Attention Puerto Rico Residents: Any person who knowingly and with the intention to defraud includes false information in an

application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits

a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a

fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the

jail term may be reduced to a minimum of two (2) years. Attention Texas Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or

other person files an application for insurance or statement of claim containing any intentional misrepresentation of material fact or conceals, for the purpose of misleading, information

concerning any fact material thereto may commit a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. Attention Vermont

Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing

any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and

may subject such person to criminal and civil penalties. Attention Virginia Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or

other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact

material thereto commits a fraudulent act, which is a crime and subjects such person to criminal and civil penalties. Attention Washington Residents: It is a crime to knowingly provide

false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

NOTE: INCOMPLETE CLAIM FORMS WILL BE RETURNED TO YOU FOR MISSING INFORMATION. THIS WILL DELAY THE PROCESSING OF THE CLAIM. FOR

FASTER, EASIER SUBMISSION OF CLAIMS, THE PROVIDER MAY CONTACT THE AETNA CLAIM PROCESSING CENTER FOR INFORMATION

REGARDING ELECTRONIC CLAIM SUBMISSIONS.

T O THE EMPLOYEE

3 B

1. Complete items one (1) through nineteen (19) in full.

2. Complete items twenty (20) through twenty-four (24) only if other medical coverage exists.

3. Be certain to sign the authorization to release information in block twenty-five (25).

4. If you wish to have your benefits for this claim paid directly to your physician or supplier, sign block twenty-six (26).

5. If you have submitted a request for benefits to another plan, including Medicare, attach a copy of the bills you submitted to the other plan and the explanation of

benefits you received from the other plan.

6. Attach itemized bills or ask your health care provider to complete the applicable section on the reverse side. The bills must include:

- patient's name

- condition being treated

- type of service(s) rendered

- date(s) of service(s)

- relationship to employee

If this information is missing, write it on the bill and sign your name.

7. If prescription drugs are covered under your plan, submit receipts or a Prescription Drug Record form. Receipt must contain:

- drug name

- purchase date

- prescription number

- pharmacy name/address

- dose per/day

- nature of illness or injury

- quantity

- charge

- strength

- physician's name

This information can be copied from the prescription bottle or box.

8. Retain copies of your bills for your record.

9. Refer to the back of your ID card for claim mailing address.

TO THE PHYSICIAN OR SUPPLIER

1. Complete items twenty-seven (27) through forty-six (46) in full.

2. If the employee indicates that benefits should be paid directly to the physician or supplier, then these benefits will be sent directly to you with an information copy of

the transactions to the employee.

GC-7 (2-12) J

R-POD