Forms

Below are a list of important member forms:

2025 Enrollment Form (English|Spanish): fill out to enroll in one of the Aetna Medicare Dual Eligible Special Needs Plans (HMO D-SNP)

Hospice form: information to override an Hospice A3 reject or to update hospice status

Prior Authorization: please fill out the form to get authorization for services

Redetermination form: you have 60 days from the date of our Notice of Denial

Coverage Redetermination form - Spanish

Coverage Redetermination form - Vietnamese

Coverage Redetermination form - Arabic

Medicare Prescription Drug Coverage Determination form

Coverage Determination form - Spanish

Coverage Determination form - Vietnamese

Coverage Determination form - Arabic

AOR Form: Please fill out If you need help with a grievance, coverage decision or appeal, you can ask someone to act on your behalf by naming another person to act for you as your “representative.”

Additional forms: Additional Forms: Authorization to Release Protected Health Information (PHI); Authorization to Release Psychotherapy Notes