Coordination of Benefits

Name of facility/provider

Patient name

1. Do you or another family member have other health coverage that may cover this claim?

If no, please provide the information within section one, sign and date. If yes, please complete all fields, sign and

date.

Name of Aetna subscriber

Date of birth Aetna member ID Patient relationship to subscriber

Name of employer group Effective date of coverage

1a. Type of other coverage

Other Aetna Health Plan Other insurance Student Health Medicaid

Other health plan name Effective date of coverage

Other health plan address

Other health plan phone number Other health plan member ID number Is the subscriber:

Active Retired On COBRA

Patient relationship to subscriber Date retired

2. If the patient is your child, please provide the following:

Patient’s name

Patient’s date of birth Patient’s ID number (if not the subscriber)

Father’s name and date of birth Mother’s name and date of birth

3. If separated or divorced, please provide the following:

Is there a court order establishing which parent is financially responsible for the dependent child(ren)’s medical, dental or other health care expenses?

Yes No If yes, specify who:

Who has custody of the dependent child(ren)? Who do the child(ren) live with? How many months of the year?

4. Do you and/or another family member have Medicare?

If yes, provide the following for each family member with Medicare.

Name of Medicare beneficiary

Medicare A Medicare B Both

Medicare member ID Entitlement reason

Age Disability End stage renal disease

Effective date

If entitled due to end stage renal disease, please provide:

The date of first dialysis

Home dialysis

Dialysis in facility/dialysis

center

Date of transplant, if applicable

You can return this form to us by fax or mail:

Aetna

PO Box 981106

El Paso, TX 79998-1106

Fax: (866) 474-4040

NOTE: Please don’t return this form without a valid signature and date.

Print Name of the person completing the form

Signature Date

GR-68954 (4-18)