Gr 68069 2025

1. Click ‘Get Form’ to open the gr 68069 in the editor.
2. Begin by filling out the Employee Information section. Enter your employer's name, your full name as it appears on your Aetna ID card, and your identification number. Don't forget to include your birthdate and contact details.
3. Next, move to the Patient Information section. Provide the patient's name, relationship to you, birthdate, and gender.
4. In the Summary of Medical, Pharmacy, Dental, and Vision Services section, list all services received along with their corresponding diagnoses. Ensure you attach any necessary documentation as specified.
5. Complete the Claim Information section by indicating if the claim is related to a work-related accident or accidental injury. If applicable, provide details about the accident.
6. Proceed to summarize reimbursement preferences in Section 5. Choose your preferred method for receiving reimbursements and fill in any required bank information if opting for funds transfer.
7. Finally, review all sections for accuracy before signing and dating the authorization at the end of the form.

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