Aetna

Founded in 1853 in Hartford, CT, Aetna is committed to providing individuals, employers, health care professionals, producers and others with innovative benefits, products and services.

Provider Finder

Form Name Effective Date Download Form
Attestation Form
01/01/2017 Download
Automated Clearing House (ACH) New Business Request
01/01/2017 Download
Aetna Employer Application - Small Group
01/01/2017 Download
CA SG New Business Checklist
01/01/2017 Download
Proof of Eligibility Form
03/05/2014 Download
Small Business Employer Administration on Manual
01/01/2017 Download
Small Employer Certification
01/01/2017 Download
Springboard Census Template
04/01/2017 Download
Transition of Care Form (HMO)
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Transition of Care Form (Traditional)
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Form Name Effective Date Download Form
Authorization to Release Protected Health Information (Spanish)
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Authorization to Release Protected Health Information Form
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Claim Form - Dental (Spanish)
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Claim Form - Dental
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Claim Form - Life
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Claim Form - Medical
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Claim Form - RX Mail Order
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Claim Form - RX
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Claim Form - Vision
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CA SG Employee Enrollment/ Change Form
01/01/2017 Download
CA SG Employee Enrollment/ Change Form - Spanish
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Dependent Care Reimbursement Form
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Health Care Reimbursement Form
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Limited FSA Over the Counter
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Limited FSA Reimbursement Form
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OTC Reimbursement Claim Form
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Vision Preferred Employee Enrollment-Change Form - Spanish
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Vision Preferred Employee Enrollment-Change Form
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Form Name Effective Date Download Form
Medical HMO
CA Platinum AVN HMO 15 Copay Plan
01/01/2017 Summary SBC
CA Platinum Basic HMO 15 Copay Plan
01/01/2017 Summary SBC
CA Gold AVN HMO 20
01/01/2017 Summary SBC
CA Gold AVN HMO 30 Copay Plan
01/01/2017 Summary SBC
CA Gold AVN HMO 45
01/01/2017 Summary SBC
CA Gold Basic HMO 20
01/01/2017 Summary SBC
CA Gold Basic HMO 30 Copay Plan
01/01/2017 Summary SBC
CA Gold Basic HMO 45
01/01/2017 Summary SBC
CA Gold Basic HMO 250
01/01/2017 Summary SBC
CA Gold HMO 20
01/01/2017 Summary SBC
CA Gold HMO 45
01/01/2017 Summary SBC
CA Gold HMO Deductible 250
01/01/2017 Summary SBC
CA Gold PrimeCare HMO 30 Copay Plan
01/01/2017 Summary SBC
CA Gold PrimeCare HMO 45
01/01/2017 Summary SBC
CA Silver Basic HMO 1500
01/01/2017 Summary SBC
CA Silver Basic HMO 2000
01/01/2017 Summary SBC
CA Silver Basic HMO 2000 Copay Plan
01/01/2017 Summary SBC
CA Silver HMO AP Deductible 2000
01/01/2017 Summary SBC
CA Silver HMO Deductible 1500
01/01/2017 Summary SBC
CA Silver HMO Deductible 2000
01/01/2017 Summary SBC
CA Silver PrimeCare HMO Deductible 1500
01/01/2017 Summary SBC
CA Bronze Basic HMO 6300 Plan
01/01/2017 Summary SBC
CA Bronze Basic HMO 6500
01/01/2017 Summary SBC
CA Bronze HMO Deductible 6500
01/01/2017 Summary SBC
CA Bronze PrimeCare HMO Deductible 6500
01/01/2017 Summary SBC
Medical PPO
CA Platinum Savings Plus 0 Copay Plan
01/01/2017 Summary SBC
CA Gold MC 0 Copay Plan
01/01/2017 Summary SBC
CA Gold MC 750 80 50
01/01/2017 Summary SBC
CA Gold PrimeCare MC 750 80 50
01/01/2017 Summary SBC
CA Gold Savings Plus 0 Copay Plan
01/01/2017 Summary SBC
CA Gold Savings Plus 750 80 50
01/01/2017 Summary SBC
CA Silver MC 1000 70 50
01/01/2017 Summary SBC
CA Silver MC 2000 60 50
01/01/2017 Summary SBC
CA Silver MC 2000 80 50 HDHP Plan
01/01/2017 Summary SBC
CA Silver MC 2000 Copay
01/01/2017 Summary SBC
CA Silver MemorialCare MC 2000 60 50
01/01/2017 Summary SBC
CA Silver PrimeCare MC 2000 60 50
01/01/2017 Summary SBC
CA Silver Providence MC 2000 60 50
01/01/2017 Summary SBC
CA Silver Savings Plus 1000 70 50
01/01/2017 Summary SBC
CA Silver Savings Plus 2000 60 50
01/01/2017 Summary SBC
CA Silver Savings Plus 2000 80 50 HDHP Plan
01/01/2017 Summary SBC
CA Silver Savings Plus 2000 Copay
01/01/2017 Summary SBC
CA Silver SCCIPA MC 2000 60 50
01/01/2017 Summary SBC
CA Bronze MC 4000 Copay
01/01/2017 Summary SBC
CA Bronze MC 6500 Copay
01/01/2017 Summary SBC
CA Bronze MC 6550 100 50 HSA
01/01/2017 Summary SBC
CA Bronze MC HDHP 4800 60 50 HSA Plan
01/01/2017 Summary SBC
CA Bronze MemorialCare MC 6500 Copay
01/01/2017 Summary SBC
CA Bronze PrimeCare MC 4000 Copay
01/01/2017 Summary SBC
CA Bronze Providence MC 6500 Copay
01/01/2017 Summary SBC
CA Bronze Savings Plus 4000 Copay
01/01/2017 Summary SBC
CA Bronze Savings Plus 6500 Copay
01/01/2017 Summary SBC
CA Bronze Savings Plus 6550 100 50 HSA
01/01/2017 Summary SBC
CA Bronze Savings Plus HDHP 4800 60 50 HSA Plan
01/01/2017 Summary SBC
CA Bronze SCCIPA MC 6500 Copay
01/01/2017 Summary SBC
Dental
CA Dental (3-9) Voluntary Active PPO $1500
Summary
CA Dental (3-9) Voluntary DMO Access Plan 42
Summary
CA Dental (3-9) Voluntary DMO Plus Plan 58
Summary
CA Dental (3-9) Voluntary Freedom-of-Choice Coinsurance
Summary
CA Dental (3-9) Voluntary PPO $1000
Summary
CA Dental (10-100) Voluntary Option 4A Ortho
Summary
CA Dental (10-100) Voluntary Option 5A Ortho
Summary
CA Dental (10-100) Voluntary Option 5B FOC Plan 66 Ortho
Summary
CA Dental (10-100) Voluntary Option 5B Ortho
Summary
CA Dental (10-100) Voluntary Option 6A Ortho
Summary
CA Dental (10-100) Voluntary Option 6A
Summary
CA Dental (10-100) Voluntary Option 7A Ortho
Summary
CA Dental (10-100) Voluntary Option 7A
Summary
CA Dental (10-100) Voluntary Option 8A Ortho
Summary
CA Dental (10-100) Voluntary Option 8A
Summary
CA Dental (10-100) Voluntary Option 8B Ortho
Summary
CA Dental (10-100) Voluntary Option 8B
Summary
CA Dental (10-100) Voluntary Option 8C Ortho
Summary
CA Dental (10-100) Voluntary Option 8C
Summary
CA Dental (10-100) Voluntary Option 9A Ortho
Summary
CA Dental (10-100) Voluntary Option 9A
Summary
CA Dental (10-100) Voluntary Option 10A Ortho
Summary
CA Dental (10-100) Voluntary Option 10A
Summary
CA Dental (10-100) Voluntary Option 10B Ortho
Summary
CA Dental (10-100) Voluntary Option 10B
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CA Dental (10-100) Voluntary Option 11A Ortho
Summary
CA Dental (10-100) Voluntary Option 11A
Summary
CA Dental (10-100) Voluntary Option 11B Ortho
Summary
CA Dental (10-100) Voluntary Option 11B
Summary
CA Dental (10-100) Voluntary Option 12A Ortho
Summary
CA Dental (10-100) Voluntary Option 12A
Summary
CA Dental (10-100) Voluntary Option 12B Ortho
Summary
CA Dental (10-100) Voluntary Option 12B
Summary
Dental (3-9) Voluntary Passive PPO $1500
Summary
Dental (3-9) Voluntary PPO $1500
Summary
CA Dental (2-9) DMO Access Plan 42
Summary
CA Dental (2-9) DMO Plus Plan 58
Summary
CA Dental (2-9) FOC Plus DMO Plan 58
Summary
CA Dental (2-9) Freedom of Choice DMO PPO Max
Summary
CA Dental (2-9) PPO $1000 Active
Summary
CA Dental (2-9) PPO $1500 Active
Summary
CA Dental (2-9) PPO $1500 Passive
Summary
Dental (2-9) PPO $2000 Active
Summary
CA Dental (10-100) Option 3A Plan 66 Ortho
Summary
CA Dental (10-100) Option 3B Plan 66l Ortho
Summary
CA Dental (10-100) Option 3C Plan 63 Ortho
Summary
CA Dental (10-100) Option 4A Ortho
Summary
CA Dental (10-100) Option 5A Ortho
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CA Dental (10-100) Option 6A Ortho
Summary
CA Dental (10-100) Option 6A
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CA Dental (10-100) Option 7A Ortho
Summary
CA Dental (10-100) Option 7A
Summary
CA Dental (10-100) Option 8A Ortho
Summary
CA Dental (10-100) Option 8A
Summary
CA Dental (10-100) Option 8B Ortho
Summary
CA Dental (10-100) Option 8B
Summary
CA Dental (10-100) Option 8C Ortho
Summary
CA Dental (10-100) Option 8C
Summary
CA Dental (10-100) Option 9A Ortho
Summary
CA Dental (10-100) Option 9A
Summary
CA Dental (10-100) Option 10A Ortho
Summary
CA Dental (10-100) Option 10A
Summary
CA Dental (10-100) Option 10B Ortho
Summary
CA Dental (10-100) Option 10B
Summary
CA Dental (10-100) Option 11A Ortho
Summary
CA Dental (10-100) Option 11A
Summary
CA Dental (10-100) Option 11B Ortho
Summary
CA Dental (10-100) Option 11B
Summary
CA Dental (10-100) Option 12A Ortho
Summary
CA Dental (10-100) Option 12A
Summary
CA Dental (10-100) Voluntary Option 1A Plan 58 Ortho
Summary
CA Dental (10-100) Voluntary Option 1B Plan 56 Ortho
Summary
CA Dental (10-100) Voluntary Option 2A Ortho
Summary
Vision
Vision Preferred Basic 12M
Summary
Vision Preferred Basic 24M
Summary
Vision Preferred Plus 12M
Summary
Form Name Effective Date Download Form
Aetna Heal Flyer
04/01/2017 Download
Aetna HMO Network Comparison
08/01/2017 Download
Aetna Teledoc Flyer
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2017 Aetna Pharmacy Drug Guide
03/01/2017 Download
CA Underwriting Brochure 1-100
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EAP Member Flyer
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EAP Plan Sponsor Broker Flyer
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EAP WalletCard
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Small Business New Customer Quick Start Guide
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Springboard Aetna Funding Advantage
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Springboard Flyer
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Springboard Rules of the Road
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Form Name Effective Date Download Form
Contact Information
01/01/2017 Download