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Aetna Permission to Contact 2026
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- Click ‘Get Form’ to open the Aetna Permission to Contact in our editor.
- Begin by entering your First Name and Last Name in the designated fields. This information is essential for identification purposes.
- Fill in your Address, City, State, and ZIP code accurately to ensure proper communication.
- Provide your Phone number and E-mail address. This allows a licensed sales representative to contact you regarding Medicare plans.
- Indicate whether you are currently Medicare eligible by selecting 'Yes' or 'No'. If 'No', specify when you will be eligible.
- If applicable, check the box indicating that you wish to be contacted between October 1 and December 7 if not eligible before October 15.
- Select any plan information you are interested in: Prescription Drug plans, Supplement plans, Advantage plans with prescription drug coverage, or Dental plans.
- Review the consent statement regarding contact from a licensed sales representative and provide your Signature and Date at the bottom of the form.
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See more Aetna Permission to Contact versions
We've got more versions of the Aetna Permission to Contact form. Select the right Aetna Permission to Contact version from the list and start editing it straight away!
| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2014 | 3.9 Satisfied (50 Votes) |
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Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services.
By completing and signing this form, I, or my legal representative, agree to allow Aetna to share my PHI with the people or companies listed below.