Forms

Below are a list of important member forms:

Enrollment form: fill out to enroll with Aetna Better Health of Ohio Dual Preferred (HMO SNP) and return to:

Aetna Better Health of Ohio Dual Preferred (HMO SNP)
7400 West Campus Rd.
New Albany, OH 43054

Hospice form: information to override an Hospice A3 reject or to update hospice status

Prior Authorization: please fill out the form to get authorization for services

Prescription Drug Coverage Redetermination Form: you have 60 days from the date of our Notice of Denial

Medicare Prescription Drug Coverage Determination form

Appointment of Representative Form: Please fill out If you need help with a grievance, coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.”

Authorization to Release Protected Health Information (PHI)

Authorization to Release Psychotherapy Notes