Fill and Sign the Treasury Authorization Form

AGB WorldTraveler Claim Form Medical SM Aetna Global Benefits® Please also complete Page 2 of this form. Pharmacy Please mail or fax completed Claim Form with itemized bills and receipts. A separate Claim Form is needed for each family member. Please tape small receipts on a full size sheet of paper. Aetna Global Benefits P.O. Box 30258 Tampa, FL 33630-3258 USA OR Aetna Global Benefits 4630 Woodland Corporate Blvd. Tampa, FL 33614 USA Telephone: Facsimile: E-mail: +1-877-301-5042 (outside the USA, via AT&T + access) +1-813-775-0190 (direct or collect outside the USA) +1-800-475-8751 (outside the USA, via AT&T + access) +1-813-775-0625 (inside the USA) agbservice@aetna.com 1. Employee Information Employer Name/Group Number Continental Airlines/299440-10-061 Employee's Name (First Name, Middle Initial, Last Name/Surname) Identification Number (Aetna assigned upon receipt of initial claim, or refer to the Explanation of Benefits (EOBs) from previous AGB WorldTraveler claim submissions.) Employee's Birthdate (mm/dd/yyyy) / / Gender Male Female Street State/Province City Country Postal/Zip Code Employee's Telephone Number (Include Country Code) Employee's Primary E-Mail Address (Email addresses are strongly encouraged in the event additional information is needed to process your claim.) 2. Patient Information Patient's Name (First Name, Middle Initial, Last Name/Surname) Self Spouse Child Other Relationship: Patient's Birthdate (mm/dd/yyyy) / / Gender Male Female 3. Summary of Medical and Pharmacy Services (Please include diagnosis or reason for treatment for each service received.) Dates of Service (mm/dd/yyyy) Provider's (physician, clinic, hospital, pharmacy) Name and Address (If the Provider’s name and address is on receipts, write “see receipts”) Description of Service/ Name of Medication/ Drug/Device (If hospital, indicate inpatient or outpatient) Diagnosis (Reason for visit) City/State/ Province/Country of Claim Currency of Claim Total Charge 4. Claim Information If Yes is answered to either question below, c and d in this section must be completed. a. Is the claim related to a work related accident or condition? Yes No b. Is the claim related to an accidental injury? Yes No c. Accident Date (mm/dd/yyyy) / / Time d. Description of Accident (How and Where) AM PM Please Retain A Copy For Your Records GR-68070 (10-08) A-POD Coverage underwritten by Aetna Life Insurance Company and Aetna Life & Casualty (Bermuda) Ltd. Page 1 of 2 Employee’s Name (First Name, Middle Initial, Last Name/Surname) 5. Summary of Reimbursement - Your Aetna Global Benefits (AGB) plan of benefits includes the option of claim reimbursements in a variety of currencies and disbursement methods. Establish your selected option in the sections below. AGB reserves the right to issue the benefit reimbursement in the mode of payment which is available for the currency type, as circumstances dictate. If you elect to be reimbursed in a U.S. dollar check, skip to Section 8. All other reimbursement methods continue with Sections 5, 6 and 7. Please check one of the following (as applicable) - if left unchecked we will observe for this claim submission only: Use the Recurring Reimbursement Election (RRE) information currently on file. Use the information provided in Sections 5 and/or 6 to establish an RRE. Update the current RRE information on file with the information provided in Sections 5 and/or 6. Use the information provided in Sections 5 and/or 6 only for expenses related to this claim form. Summary of Reimbursement (Method/Currency Type) – Only one method of reimbursement and currency will be honored per claim form. (Unless otherwise indicated, reimbursements will be made via US$ check and payable to the party to which payment is sent.) Use the information provided below to send any applicable reimbursement payment to: Employee Provider Country/Currency Type for Reimbursement (i.e., Great Britain / Pounds) If the currency you have elected is not available for the method requested, we will default reimbursement to US$. Requested Reimbursement Method Funds Transfer (Preferred) The most efficient method of receiving your benefits reimbursement is via Funds Transfer. Please check with your bank for help with providing the appropriate instructions to AGB. (Complete the Country/Currency and go to Section 8.) Check 6. Bank Information Primary Bank –The following information is required if you have elected Funds Transfer as your preferred method for reimbursements. AGB will transfer funds to your bank at no cost to you; however, we encourage you to check with your bank to determine any additional fees your bank may charge you for receiving Funds Transfer(s). Bank Account Number Name of Accountholder (As it appears on the Bank Statement) Bank Identification Code/Routing Number S.W.I.F.T./BIC Code (wire only) CHIPS UID Federal ABA Bank Name Bank Address (Include Country) Bank Telephone Number (Include Country Code) Bank Sort ID IBAN Other 7. Other Health Coverage/Scheme Are any family members’ expenses covered by another health plan/scheme, Medicare, or any U.S. Federal, U.S. State, National, Social government plan? Yes No If "Yes," please complete information below. Name and Relationship of the Family Member (First Name, Middle Initial, Last Name/Surname) Family Members Birthdate (mm/dd/yyyy) / / Gender Male Female Name of other Insurance Company or Type of Insurance 8. Authorization (Required) For All Electronic Deposits: I hereby authorize Aetna Life & Casualty (Bermuda) Ltd., Aetna Life Insurance Company, and any of their affiliated companies (“Aetna”) and/or their dedicated Agents to make payments of any benefits payable to me and/or my dependents, by crediting such payments to my account at the bank or financial institution named on this form. I agree to notify Aetna in writing of any changes relating to the information provided on this form or withdrawal of this authorization. I agree that if, for any reason, unearned benefit payments are deposited into my account, I will immediately repay the full amount of any such payments. I further agree that if I do not immediately repay such payments, I will personally be liable for all costs of collection (including reasonable attorney’s fees and the maximum interest permitted by law). Medical and Pharmacy Authorization. Must be signed and Dated: I authorize all physicians, other health professionals, pharmacies/pharmacists, hospitals and health care institutions to provide Aetna and any independent parties acting on Aetna’s behalf or with whom Aetna has contracted, information concerning health care, advice, treatment or supplies provided to the Patient (including that related to mental illness and/or AIDS/ARC/HIV). This information will be used for the purposes of evaluating and administering claims. Aetna may provide the employer named on this form with any benefit calculation used in the payment of this claim for the purpose of reviewing the experience and operation of the policy/contract. This authorization is valid for the term of the policy or contract under which a claim is submitted. I know I have a right to receive a copy of this authorization upon request and agree that a copy of this authorization is as valid as the original. Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to claim was provided by the applicant. Date (mm/dd/yyyy) Patient's or Authorized Person's Signature Please Retain A Copy For Your Records GR-68070 (10-08) Coverage underwritten by Aetna Life Insurance Company and Aetna Life & Casualty (Bermuda) Ltd. Page 2 of 2