Skip to main content

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.

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).