Please return this form and any attachments to:
7. Member's Daytime Telephone Number
( )
11.Patient's Relationship To Member
□ Self □ Spouse □ Child □ Other
14. Member's ID Number 16. Member's Birthdate (MM/DD/YYYY)
19. Summary of the Accident:
□ Yes □ No If Yes, answer Section 22. If No, skip to Section 23.
* Claims can be mailed to address located at top right side of this form or faxed directly to 1-859-455-8650.
** If outside of Mercer, Middlesex or Somerset Counties in NJ and Bucks County in PA, no referral needed.
17. Is claim related to an accident? □ Yes □ No If Yes, go to Sections 18-24 If No, skip to Section 25
□ Other (Go to Section 28)
AETNA STUDENT HEALTH CLAIM FORM
TO BE COMPLETED BY MEMBER (Please Print)
5. Member's Birthdate (MM/DD/YYYY)
3. Member's Aetna ID Number
W
12. Are your or any family members' expenses covered by another group health
plan, group pre-payment plan (Blue Cross-Blue Shield, etc.), no fault auto
insurance, Medicare or any federal, state or local government plan?
10. Patient's Birthdate (MM/DD/YYYY)
18. COMPLETE THIS SECTION FOR AN ACCIDENT CLAIM
25. COMPLETE THIS SECTION FOR MEDICAL/DENTAL CLAIMS
Were you treated at University Health Services for this condition?
□Yes If Yes, go to Section 13 □No If No, go to Section 17
23. Was injury work related?
Did you receive a referral? □ Yes □ No
□ Vaccination (Go to Section 29)
13. List policy or contract holder, policy or contract number(s) and name/address of
insurance company or administrator:
Note: If you do have another insurance plan, Aetna Student Health is considered
your secondary plan.
9. Patient's Aetna ID Number
W
□ Mental Health (No referral required) (Go to Section 29)
GO TO SECTION 29 TO COMPLETE FORM
21. Was injury due to practice/play of NCAA sponsored sport?
If yes, please attach auto voucher.
20. Location where accident occurred:
24. Is condition due to an auto accident?
29. Attach itemized bills. The bills must include:
-
patient's name
-
condition being treate
d
-
dates(s) of service(s) - type of service - proof of payment
If you have submitted a request for benefits to another insurance plan, attach a
copy of the bills you submited to the other plan and the explanation of benefits
you received from the other plan.
Retain copies of your bills for your record.
Sign and date below.
6. Member's Address (include ZIP CODE) □ Address is new
26. □ Preventative Dental (Go to Section 29)
□ Complimentary Medicine/Physical Therapy (Go to Section 27)
Instructions: Check claim type in Section 26. Go to corresponding section.
Complete claim form with signature and date. Attach receipt as described in
Section 29. Send claim to Aetna Student Health at address located at top right
side of this form.*
27. COMPLIMENTARY MEDICINE / PHYSICAL THERAPY CLAIM
Did you receive a referral? □ Yes □ No
Were you treated at University Health Services for this condition?
Were services obtained outside the Princeton vicinity**? □ Yes □ No
Were services obtained during a break period? □ Yes □ No
SIGNATURE _______________________________________________________ DATE _____________________________
