Aetna ub4 claim form 2026

1. Click ‘Get Form’ to open the Aetna UB4 Claim Form in the editor.
2. Begin with Section A, where you will enter the Provider’s name and mailing address. If filing as a medical group, include the group's name.
3. In Section B, provide details for an Authorized Agent if applicable. This includes their name, address, and Tax Identification Number.
4. Proceed to Section C to fill in the contact person's information, including their name, company name, phone number, and email address.
5. In Section D, indicate the number of claims you are seeking reimbursement for.
6. Refer to Section E for instructions on supporting documentation. Ensure you attach necessary documents as specified.
7. Complete Sections F and G by signing and dating the form to certify accuracy and authority.
8. Finally, follow Section I's mailing instructions carefully to ensure your claim is submitted correctly and on time.

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