Conditions of Enrollment
Applicant Acknowledgments and Agreements
On behalf of myself and the dependents listed on the reverse side, I agree to or with the following:
1. I acknowledge that by enrolling in an Aetna plan coverage is underwritten or administered by Aetna Life
Insurance Company (referred to as "Aetna").
2. I authorize deductions from my earnings for any contributions required for coverage and I agree to make any
necessary payments as required for coverage.
3. I understand and agree that this Enrollment/Change Request may be transmitted to Aetna or its agent by my
employer or its agent. I authorize any physician, other healthcare professional, hospital or any other
healthcare organization ("Providers") to give Aetna or its agent information concerning the medical history,
services or treatment provided to anyone listed on this Enrollment/Change Request form, including those
involving mental health, substance abuse and HIV/AIDS. I further authorize Aetna to use such information
and to disclose such information to affiliates, providers, payors, other insurers, third party administrators,
vendors, consultants and governmental authorities with jurisdiction when necessary for my care or
treatment, payment for services, the operation of my health plan, or to conduct related activities. I have
discussed the terms of this authorization with my spouse and competent adult dependents and I have
obtained their consent to those terms. I understand that this authorization is provided under state law and
that it is not an "authorization" within the meaning of the federal Health Insurance Portability and
Accountability Act. This authorization will remain valid for the term of the coverage and so long thereafter as
allowed by law. I understand that I am entitled to receive a copy of this authorization upon request and that
a photocopy is as valid as the original.
4. The plan documents will determine the rights and responsibilities of member(s) and will govern in the event
they conflict with any benefits comparison, summary or other description of the plan.
5. I understand and agree that with the exception of Aetna Rx Home Delivery, all participating providers and
vendors are independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home
Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed
and provider network composition is subject to change. Notice of the change shall be provided in
accordance with applicable state law.
Instructions
Employer -
Complete the Employer Group Information at the top of the form.
Section A - Type of Activity:
•
Check box(es) indicating reason(s) for submitting this Enrollment/Change Request.
•
Provide Effective Date(s) and Date of Event(s) where requested.
Section B - Employee Information:
•
Complete all information in order for your Enrollment/Change Request to be processed.
•
Beneficiary Designation - Complete only if your employer is offering Aetna Life Insurance coverage.
Section C - Plan Options:
Select only an option offered by your employer.
Section D - Individuals Covered:
•
Add/Change/Remove - Use "A", "C", or "R" to indicate whether you are adding, changing or removing coverage for an
individual.
•
Print your full name along with the name(s) of your dependent(s), if applicable. Indicate Sex, Birthdate, and Social
Security Number for each individual listed.
•
Relationship Code - Use ONLY: H=Husband, W=Wife, S=Son, D=Daughter, Y=Sponsored Male, X=Sponsored
Female. If the dependent is NOT your spouse or a biological or legally adopted child, please indicate
relationship to employee in Special Remarks.
•
If you or your dependent(s) were covered under your employer's or other Prior Insurance Plan or currently have
Other Medical Coverage, check the "Yes" box(es) and provide beginning and ending effective dates, name and
policy number of insurance carrier, HMO or other source and your Member Identification Number in the space
provided in Number 1.
•
If you or your dependent(s) have Other Rx Drug Coverage, check the "Yes" box and provide beginning and ending
effective dates, name and policy number of insurance carrier, HMO or other source and your Member Identification
Number in the space provided in Number 2.
•
NOTE: In some instances your medical carrier will differ from your Rx Drug carrier.
•
If a dependent is Handicapped and financially dependent, check "Yes" and provide proof of handicapped status from
the attending physician.
•
If a dependent is a Student, check "Yes". Refer to your Summary Coverage for plan definitions. Aetna may request
that you provide proof from the educational institution.
•
Primary Medical Office ID Number - Locate the office ID number for the primary care physician from the appropriate
provider directory or from "DocFind
®
", Aetna's online provider directory at "www.aetna.com".
•
If you are a current patient, please check the "Yes" box under Current Patient.
•
Optional
- Using the KEY provided, please enter the Race/Ethnicity code for each individual. If your Race/Ethnicity is
"Other," print the Race/Ethnicity for each individual in the space provided.
Section E - Employee Signature:
•
Complete this section for all new enrollments or coverage changes.
•
Employee must sign and date the Enrollment/Change Request in order for it to be processed.
•
By checking the box on the reverse side you agree to use Aetna Navigator, Aetna's member self-service website, for
all future printed materials.
Employee - Complete Sections A - E.
Misrepresentation
Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals, for
the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance
act, which is a crime and subjects such person to criminal and civil penalties.
PA (9-05) GR-68000-20
