Forms

Below are forms that you may need as a member of Aetna Better Health of Ohio. These forms can help you manage claims, access information and more. If you need a form not listed here, contact us.

Authorization to Release PHI (English/Spanish)

Authorization to Release Psychotherapy Notes (English/Spanish)

PHI Access Request (English/Spanish)

Removal of Authorization Previously Given (English/Spanish)

Request for an Accounting Disclosures of PHI (English/Spanish)

Notice of Privacy Practices (English/Spanish)

Privacy Request Form

Appointment of Representative Form

Prior Authorization Form

Behavioral Health Prior Authorization Form

Transition of Care

Prescription Drug Mail Order Form (English & Español)

Coverage Determination Form

Coverage Redetermination Request Form

Medicare Part D Prescription Claim/Reimbursement Form (English & Español)

Hospice Part D Exception Form

Advance Directive Information

Member Advisory Committee Application