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Member materials and forms

Here, you’ll find the info and forms you need to get the most from your plan.

Materiales para miembros


Member handbook ― English (PDF) | Spanish (PDF)



Authorization release for grievance/appeal form (PDF)


CVS mail order form ― English (PDF) | Spanish (PDF)


State fair hearing request form (PDF)


Authorization form to release protected health information ― English (PDF) | Spanish (PDF)


Authorization form to release psychotherapy notes ― English (PDF) | Spanish (PDF)


Protected health information access request form ― English (PDF) | Spanish (PDF)


Request form for an accounting of disclosures of protected health information ― English (PDF) | Spanish (PDF)


Request form to remove authorization previously given to Aetna Better Health ― English (PDF) | Spanish (PDF)


Fraud, waste and abuse form

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