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18594558650 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the Employer Information section. Enter the employer's name, control number, and address including ZIP code.
- Next, complete the Employee Information section. Provide your Social Security Number, name, birthdate, address, and daytime telephone number. Indicate your basic income and describe your job duties.
- In the Claim Information section, specify if your absence is work-related and if it is related to an accident. Provide details about the nature of your illness or injury and expected return to work date.
- Complete the Release section by signing and dating it. Ensure you understand that this authorization allows Aetna to obtain necessary health information.
- Finally, review all sections for accuracy before submitting. You can easily save or print your completed form directly from our platform.
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