The Internal Revenue Service (IRS) issued a Notice in 2019 related to information reporting requirements that were added by the Affordable Care Act (ACA). People generally receive only one version, though some may get both a 1095-B and a 1095-C. Revocation of Authorization (Spanish - PDF)ġ095-A comes from the federal government Federal Exchange Marketplace or state-based Exchange Marketplace.ġ095-B comes from your insurance company. Revocation of Authorization (English - PDF) Use this form to remove permission previously given 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.Īuthorization to Release Protected Health Information (English - PDF)Īuthorization to Release Protected Health Information (Spanish - PDF) Use this form to give us permission to share information about you (or a dependent) with another person or company. Infertility: Donor, Surrogate or Gestational Carrier Expense Reimbursement Form (PDF) Vision Claim Form for vision benefits through the Aetna Vision Preferred Plan (Spanish - PDF) Vision Claim Form for vision benefits through the Aetna Vision Preferred plan (English - PDF)

Vision Claim Form for vision benefits within a medical plan (PDF) If you get a bill or receive care from a health care professional who is not in the Aetna network, and you need to submit a claim, please complete and mail one of the forms below to the address on your ID card. (Some out-of-network health care professionals also may submit claims for you.) Ask your doctor or other health care professional if you need to submit a claim.

Health care professionals in our network should file claims for you.

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