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Forms for Members

Authorization for Release of Protected Health Information (PHI) (third party)

Autorización para divulgar información protegida de salud

Request for Protected Health Information (PHI)

Formulario de solicitud de acceso a la informacion medica protegida (PHI)

Revocation of Authorization previously given to Aetna (Third party)

Member Complaint and Appeal

Medical Claim Form

Dental Claim Form

Vision Claim Form - Benefit as part of your medical plan

Vision Claim Form - Benefit through Aetna Vision Preferred

Pharmacy Claim Form

Aetna Specialty Pharmacy® Form

Effective solutions that fit a variety of needs

Our health coverage solutions bring together local expertise with the experience of a leading national insurance brand. We provide plans that deliver the services members value with the type of cost clarity that gives peace of mind.

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Legal Notices: Health benefits and health insurance plans contain exclusions and limitations.

Health benefits and health plans are offered, underwritten or administered by Allina Health and Aetna Insurance Company (Allina Health | Aetna).  Allina Health l Aetna is an affiliate of Aetna Life Insurance Company and its affiliates (Aetna).  Allina Health | Aetna has sole responsibility for its products and services. Aetna provides certain management services to Allina Health | Aetna. Aetna and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-branded walk-in clinics) are both within the CVS Health family.

Allina Health | Aetna is the brand name used for products and services provided by Allina Health and Aetna Insurance Company.

This material is for information only and is not an offer or invitation to contract. Health benefit plans contain exclusions and limitations. Providers are independent contractors and not our agents. Provider participation may change without notice. We do not provide care or guarantee access to health services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability are subject to change and may vary by location. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are part of the delivery system or physician group. Information is believed to be accurate as of the production date; however, it is subject to change.

*Applies only to covered services at MinuteClinic. Members in indemnity plans are not eligible for this benefit. Such members should refer to their benefit plan documents in order to determine coverage and applicable cost share for walk-in clinic benefits and services, as applicable. Visit MinuteClinic.com for age and service restrictions. Eligible members enrolled in qualified high-deductible plans must meet their deductible. However, such services would be subject to negotiated contract rates. Once the deductible has been met, members will be able to access MinuteClinic services at no cost share. Aetna and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-branded walk-in clinics) are both within the CVS Health family. Aetna is not responsible for services received at MinuteClinic locations. 98point6 and 98point6 physicians are independent contractors and are neither agents nor employees of Allina Health | Aetna or plans administered by Allina Health | Aetna and does not guarantee that a prescription will be written.