Overpayment Refund Request

P.O. Box 30969,
Amarillo, TX 79120

866.434.8303
aetnaseniorproducts.com

If you are in need of a refund request letter in order to send a refund check please fill in the following fields then click the SUBMIT button at the bottom of the page.

PATIENT'S NAME:^*

POLICY NUMBER:^*

CLAIM NUMBER:

DATE OF SERVICE:^*

OVERPAYMENT AMOUNT:^* $

REASON FOR REFUND:

PROVIDER NAME:^*

PROVIDER'S ADDRESS TO MAIL THE REQUEST:

Provider's Address Line 1:^*

Provider's Address Line 2:

City:^*

State:^*

Zip Code:^*

PROVIDER'S TAX ID NUMBER:^*

PROVIDER'S PHONE #:^*

REQUESTED BY:^*

Aetna Senior Supplemental Insurance includes: all products underwritten by American Continental Insurance Company(ACI) and Continental Life Insurance Company of Brentwood, Tennessee(CLI), both Aetna companies; Medicare Supplement underwritten by Aetna Health and Life Insurance Company(AHLIC), Aetna Health Insurance Company(AHIC), Aetna Life Insurance Company(ALIC), Coventry Health and Life Insurance Company(CHL) and First Health Life & Health Insurance Company(FHL); Medicare Supplement underwritten by Genworth Life and Annuity Insurance Company(GLAIC) and Genworth Life Insurance Company(GLIC), both Genworth companies with policy administration by Aetna Life Insurance Company and its affiliates.

CGFLP02534

051324