Claim Form - Aetna Life Insurance Company printable pdf download

CLAIM FORM

Please return this form and any

attachments to:

AETNA LIFE INSURANCE COMPANY

CHICKERING CLAIMS ADMINSTRATORS, INC.

P.O Box 15708

Non-completion of this form may result in delay or denial.

Boston, MA 02215-0014

If other insurance exists, attach payment or denial.

PART 1: To be completed by student (Please Print)

SCHOOL

STUDENT NAME

PATIENT NAME (IF DIFFERENT)

STUDENT SOCIAL SECURITY NUMBER

STUDENT ID NUMBER

PATIENT DATE OF BIRTH

ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

IS PATIENT INSURED UNDER

(IF “YES” GIVE NAME & ADDRESS OF UNION, ASSOCIATION, OR COMPANY & POLICY NO )

I S PATIENT INSURED UNDER

ANY OTHER HEALTH INSURANCE PLAN?

MEDICARE OR MEDICAID?

Yes

Effective date of other coverage: ____________________

Parents

Spouse

Other

Name of Insured: _____________________ Subscriber ID#: _____________________

PLEASE SEND PAYMENT TO: PROVIDER

SIGNATURE

(PLEASE ATTACH PROOF OF PAYMENT)

COMPLETE THIS SECTION FOR AN ACCIDENT CLAIM

COMPLETE THIS SECTION FOR A SICKNESS CLAIM

Date of sickness: _______________________________________________________

Exact nature of injury:

Date symptoms first noticed: ____________________________________________

Details: _______________________________________________________________

What is the exact nature of this sickness:

How:

_____________________________________________________________________

When:

Have you ever had the same or similar condition? _____________________________

Where:

If yes, date of first treatment: _____________________________________________

Date of last treatment: ___________________________________________________

Was injury due to practice / play of intercollegiate or club sports?

Name and address of treating physician:

Which sport?

_____________________________________________________________________

If sports related, please attach verification from athletic trainer.

_____________________________________________________________________

Is condition work related?

Yes

_____________________________________________________________________

Is condition due to an accident?

Yes

Were you treated in the Health Service at your school for this condition? (This may

If yes, please attach auto voucher.

include Health Service, Counseling Service and Alcohol and Drug Services)

Where were you treated in the Health Service at your school for this condition? (This

_____________________________________________________________________

May include Health Service, Counseling, and Alcohol and Drug Services):

Seen by: _____________________________________________________________

Seen by:

If your claim is for services outside of the Health Service, were you referred?

If your claim is for service outside of the Health Service were you referred?

Yes

If not, why?

Away from school

Winter/Spring Break

Summer

Weekend

Other ______________________________________________________________________________________________

____________

If this accident or sickness has resulted in an outpatient hospital admission, have you obtained pre-certification?

FAILURE TO COMPLY WITH NOTIFICATION REQUIREMENT WILL RESULT IN A PENALTY (See brochure for details)

AUTHORIZATION FOR MEDICAL INFORMATION

To all Physicians, Hospitals, or other Health Professionals:

You are authorized to provide Chickering Claims Administrators, Inc. and any independent consulting health professional or auditor acting on its behalf or that of the insurance

company information concerning health care, advice, treatment or supplies provided to the patient, including that relating to mental illness or substance abuse. This information will

be used for evaluating and administering claims for benefits.

This authorization is valid for the term of coverage. I agree that a photocopy is as valid as the original.

SIGNATURE_______________________________________________________________

DATE: ___________________________________________

Parent, Guardian, Adult Claimant