Aetna Order Form – Fill Out and Use This PDF

The Aetna Order Form is a tool that allows you to create an account, register your products and services, manage payments and claims, process forms, review your policy information.

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Aetna Order Form PDF Details

Aetna Order Form is a document that, in conjunction with the Aetna Member Guide and other materials, provides standardized information about the various types of health care services available to members under Aetna's usual and customary (U&C) provider network. This guide includes general information about what you need to know before your visit; how to request an appointment; what happens when you call for medical advice or treatment; what records to bring with you when visiting our providers; and much more! This blog post will provide helpful tips on understanding and using the order form. It also offers valuable insight into submitting claims for reimbursement.

You might find it beneficial to know how much time you'll need to fill in this aetna order form and just how long the form is.

Question	Answer
Form Name	Aetna Order Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	221
Avg. time to fill out	22 min 23 sec
Other names	aetna otc order online, aetna otc catalog 2021 login, aetna medicare otc catalog 2021, aetna medicare cvs otc catalog 2021

12

Form Preview Example

Order Form

Simply follow these easy steps to start using Aetna Rx Home Delivery®:

First Time Customers New Prescriptions

1.Complete Sections A, B and C of the Order Form.

2.Complete the Patient Registration Form.

3.Mail the Order Form and Patient Registration Form with your prescription(s) and method of payment to us. Please print your name, address, date of birth and member ID on each prescription.

Please mail all orders to:

Aetna Rx Home Delivery

P.O. Box 829518

Pembroke Pines, FL 33082-9913

Returning Customers New Prescriptions or Reﬁlls of existing prescriptions

1.Complete Sections A, B and C of the Order Form.

2.Complete the Patient Registration Form ONLY if your member information has changed.

3.Mail the Order Form and Patient Registration Form with your prescription(s)

and method of payment to us. Please print your name, address, date of birth and

member ID on each prescription.

Reﬁll orders can also be placed by visiting www.aetna.com/aetnarxhomedelivery

or by calling 1-800-227-5720 (TDD: 1-800-823-6373).

Method of Delivery: ❏ Standard ❏ Rush (additional charges apply)

SECTION A

Your Name			Date of Birth

Your Aetna Member ID			Medicare Part B# (if you have one)

Home Address		City	State	ZIP

Check here if home address is new	❏

Day Phone	Evening Phone	Cell Phone	E-mail

Shipping Address (If different than home address) Please note: Address information entered here will only be used for this order.

Name

Address

City

State

ZIP

SECTION B

Name

Aetna Member ID

Medication Name and Strength

Prescribing Physician Name and Phone Number

Brand Only If Ordering a Reﬁll: Enter

(X)Reﬁll Numbers Below

We will automatically substitute FDA-approved generic medications for brand-name medications when (1) a generic equivalent medication is available and (2) your doctor’s prescription instructions allow. If you do not want us to substitute a generic, you must check “Brand Only” above for the medication(s) you want dispensed as brand only. If a member chooses a brand-name drug when a generic alternative is available (regardless of the reason), they may be subject to a higher copay.

In most instances, we are unable to provide refunds for returned medications. If you have questions about your order or our return policy, please call Customer Service at 1-800-227-5720.

SECTION C

To estimate the cost of your medications, visit www.aetna.com and log in to AetnaNavigator™. Look for the “Take Action on Your Health” tab, then select “Cost of Care.” The cost of your medication can be found on the “Prescription Drugs” link. You may also call the toll-free number on your Aetna member ID card for medication cost information.

Method of Payment: Make a check or money order payable to Aetna Rx Home Delivery or use your personal credit or debit card. Please do not send cash. Important Information:

■If you do not include a method of payment with your order and a previous order was paid for by credit or debit card, we will use that credit or debit card as the method of payment on this order.

■If you have an unpaid balance with our pharmacy this order may not be processed until payment is received.

■If you have a Flexible Spending Account (FSA) auto-debit feature, or are enrolled in an Aetna HealthFund® or Vital Savings on HealthSM plan, please provide a personal credit or debit card to cover any expenses that may exceed your account balance.

■If you are enrolled in an FSA, Health Savings Account (HSA) or Vital Savings on Health program and have a FSA/HSA/Vital Savings on Health debit card, you can use your card for payment (please also provide a personal credit or debit card to cover any expenses in excess of your account balance).

■Providing a credit or debit card will help prevent delays in order processing that result from insufﬁcient payment.

MC/VISA/AmEx/Discover or debit card number	Expiration Date
FSA/HSA debit card number	Expiration Date

Cardholder Name	Signature

The credit and/or debit cards used in processing this order will be billed for medication order costs, rush shipping costs (if applicable) and any outstanding balances. They will also be billed for all future orders unless you provide a different form of payment.

Total amount enclosed (if paying by check or money order)

18.09.308.1-FL WEB (1/08) S5810_7D_50931 (1/2006)

Fill out thefollowing section if this is your ﬁrst order with Aetna Rx Home Delivery or if this information has changed.

Please complete the following for EACH family member covered under your Aetna pharmacy beneﬁt. Select “None” for family members with no allergies or health conditions. For your convenience, this information will be included as part of your family’s proﬁle with Aetna Rx Home Delivery. We will use this information to check for potential drug interactions and allergies to medications.

For the ﬁelds below, mark with an (X) unless otherwise noted.

Member Information

••

Allergies	Health Conditions

FAMILY MEMBER NAME

<![endif]>Spanish preferred*

<![endif]>Date Of Birth

<![endif]>(MM/DD/YYYY)

<![endif]>Gender (M/F)

<![endif]>Relationship to Subscriber (S)pouse, (C)hild, (O)ther

<![endif]>None

<![endif]>Penicillin

<![endif]>Sulfa

<![endif]>Aspirin

<![endif]>Thyroid

<![endif]>Diabetes

<![endif]>Glaucoma

<![endif]>Heart Conditions

<![endif]>High Blood Pressure

<![endif]>Ulcer

<![endif]>Epilepsy

FAMILY MEMBER NAME

Other allergies or health conditions not listed above (please specify)

If you or a family member has diabetes, indicate the type of supplies being used below:

Name

Monitor

Lancets

Test Strips

Number of tests per day

If you have secondary insurance through another carrier, check here ❏

Please note: By submitting this form, you authorize the release of all the foregoing information to Aetna Rx Home Delivery, LLC, and its afﬁliates.

Aetna Rx Home Delivery now offers our customers the ability to make payments over the phone for balances due. If you would like to use this payment option, let our Customer Service Associate know and your bank account will be electronically debited for the balance due. The ﬁrst time you use this service, our Associate will ask you to verify your name, address and some additional information to help us uniquely identify you and secure your transaction. You will then be asked to select a User ID and authorization number, which will be required for future “check by phone” transactions.

When you provide a check as payment, you authorize us to use information from your check either to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day [you make] [we receive] your payment[, and you will not receive your check back from your financial institution].

Please note Aetna Rx Home Delivery's standard shipping practice is to send all medication orders on an account to the health plan subscriber. For example, a family member's order will be sent to the subscriber's address. If you wish to make alternative shipping arrangements please call Customer Service.

*For your convenience, Aetna Rx Home Delivery maintains a staff of Spanish-speaking customer service representatives.

18.09.308.1-FL WEB (1/08)	•	•
S5810_7D_50931 (1/2006)		©2008 Aetna Inc.

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