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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.

 

Notice of Privacy Practices (Eng/Spa)

Privacy Request Form

Appointment of Representative Form

Authorization to Release Protected Health Information (PHI)

Authorization to Release Psychotherapy Notes

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

 

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Copyright © Aetna Better Health of Ohio, All Rights Reserved.

 

Aetna Better Health® of Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. 

 

ATTENTION: If you speak Spanish or Somali, language assistance services, free of charge, are available to you. Call 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

ATENCIÓN: Si habla español o somalí, tiene a sudisposición servicios gratuitos de asistencia lingüística. Llame al 1-855-364-0974 (TTY: 711), durante las 24 horas, loos 7 días de la semana. La llamada es gratuita.

FIIRI: Haddii aad ku hadasho Isbaanish ama Soomaali, adeegyada lluqadda, oo bilaash ah, ayaa laguu heli karaa adiga. Wac 1-855-364-0974 (TTY: 711), 24 saacadood maalintii, 7 maalmood todobaadkii. Wicitaanku waa bilaash.

 

 

H7172_ABHOHWEBSITE_2021_C

CMS Approved: 2/8/2021

Last Updated: 2/9/2021

 

 

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