Resources and Forms
Contact us
All customer service inquiries, including Provider network questions, should be directed to Aetna Student Health. Visit the Contact Us page to call or email.
Claim forms
If the Provider does not file the claim directly with Aetna Student Health, then you can file the claim by submitting an Aetna Claim Form along with an itemized bill and proof of payment (if you paid for the service) immediately after treatment to us. Always retain copies for your records.
The documents listed below are in PDF format.
Print an Aetna Claim Form
For prescription drug claims, to receive reimbursement, you will need to submit a claim form and the prescription receipt to Aetna.
Print an Aetna Prescription Drug Claim Form
Fax your completed Aetna Prescription Drug Claim Form and receipts to 1-888-472-1128 or mail it to:
Aetna Pharmacy Management
P.O. Box 52444
Phoenix, AZ 85072-2444
Personal health information requests
Please note these forms are fillable and have digital signature capabilities when opened in Adobe Reader.
Authorization for Release of Protected Health Information (PHI) (third party authorization)
Use this form to give us permission to share information about you (or a dependent) with another person or company. You can also choose the types of coverage for which the permission applies.
Request for Protected Health Information
Use this form to get a report that included the Protected Health Information Aetna used to administer health benefits. A separate form must be completed for each member who wants to receive this report.
Revocation of Authorization previously given to Aetna (Third party authorization)
Use this form to remove permission previously given to share information about you (or a dependent) with another person or company.
Claim forms
If the Provider does not file the claim directly with Aetna Student Health, then you can file the claim by submitting an Aetna Claim Form along with an itemized bill and proof of payment (if you paid for the service) immediately after treatment to us. Always retain copies for your records.
Print an Aetna Claim Form (PDF)
For prescription drug claims, to receive reimbursement, you will need to submit a claim form and the prescription receipt to Aetna.
Print an Aetna Prescription Drug Claim Form (PDF)
Fax your completed Aetna Prescription Drug Claim Form and receipts to 1-888-472-1128 or mail it to:
Aetna Pharmacy Management
P.O. Box 52444
Phoenix, AZ 85072-2444
Personal health information requests
Please note these forms are fillable and have digital signature capabilities when opened in Adobe Reader.
Authorization for Release of Protected Health Information (PHI) third party authorization (PDF)
Use this form to give us permission to share information about you (or a dependent) with another person or company. You can also choose the types of coverage for which the permission applies.
Request for Protected Health Information (PDF)
Use this form to get a report that included the Protected Health Information Aetna used to administer health benefits. A separate form must be completed for each member who wants to receive this report.
Revocation of Authorization previously given to Aetna - third party authorization (PDF)
Use this form to remove permission previously given to share information about you (or a dependent) with another person or company.
