18594558650 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Employer Information section. Enter the employer's name, control number, and address including ZIP code.
3. 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.
4. 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.
5. Complete the Release section by signing and dating it. Ensure you understand that this authorization allows Aetna to obtain necessary health information.
6. 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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