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Member Request for Estimate Form

Get an estimate for out-of-network service costs

Members can obtain an estimated cost for out-of-network services by completing the appropriate Member Request for Estimate Form, or by visiting the FAIR Health, Inc.* website.

*FAIR Health Marks and the FAIR Heath Logo are trademarks or registered trademarks of FAIR Health, Inc. 

Accessibility Services: If you are a person with a disability who needs assistance using our websites (or mobile apps) our Customer Service representatives can assist you. Please call them at 877-480-4161. Relay services for individuals with a hearing disability are available by dialing 711.

If you need a PDF document in an accessible format, you can request it directly by completing this online form.

77 South Bedford Street Burlington, MA 01803. Aetna Student Health Agency Inc. is a duly licensed broker for student accident and health insurance in the Commonwealth of Massachusetts. Massachusetts license number: 10041444. California license number: OB84599.

Fully insured student health insurance plans are underwritten by Aetna Health and Life Insurance Company. Self-insured plans are funded by the applicable school, with claims administered on services provided by Aetna Health and Life Insurance Company. Aetna Student HealthSM is the brand name for products and services provided by Aetna Health and Life Insurance Company and its applicable affiliated companies (Aetna).