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Is this claim a result of an auto, work, or intercollegiate sports accident?
INDIANA UNIVERSITY HEALTH CENTER CLAIM FORM
(USE THIS FORM ONLY FOR SERVICES RENDERED
AT THE IU HEALTH CENTER and IUPUI HEALTH SERVICES)
Insurance Plan (check one)
International Student (812849) Prof Students (812801)
Student Name (as it appears on your Aetna ID card) Patient Name (if not the student)
ID Number (as it appears on your Aetna ID card Patient Date of Birth
/ /
Address City State Zip
Telephone Number
PLEASE KEEP COPIES OF ALL DOCUMENTS FOR YOUR RECORDS.
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Is the Itemized Receipt from the IU Health Center included?
Yes No
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Are the detailed pharmacy receipts showing drug name, dosage, and cost
included (if applicable)?
Yes No
•
Is your name and ID number clearly listed on each page? Failure to do so
may result in a delay in reimbursement.
Yes No
Yes No
If yes, provide details:
To expedite processing, please include
the following
AUTHORIZATION OF FOR MEDICAL INFORMATION
To all Physicians, Hospitals, and other Professionals:
You are authorized to provide Aetna Student Health and any independent consulting health professional or auditor acting
on its behalf or that of the insurance company information concerning health care, advice, treatment or supplies provided
to the patient, including that relating to mental illness or substance abuse. This information will be used for evaluating and
administering claims for benefits. This authorization is valid for the term of coverage. I agree that a photocopy is as valid as
the original.
Signature _________________________________________________ Date ______________________________
(If under 18, parent or guardian signature)
Please return this form and applicable attachments to:
