Form GR-67834-1 Enrollment/Change Form - Aetna - Florida

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NOTE: Before submitting this completed form to your employer, you may wish to protect the confidentiality of your
health information by taping or stapling the form so that pages 2 and 3 are not visible.
Florida Small Group Business (2 - 50 Eligible Employees)
Employee Enrollment/Change Form
Life, Accidental Death & Dismemberment, Disability, Aetna Managed Choice, and Aetna PPO plans are underwritten by Aetna Life
Insurance Company. Aetna HMO and Aetna POS plans are underwritten by Aetna Health Inc. Dental plans are provided or
Member Aetna ID Number (if available)
administered by Aetna Life Insurance Company.
Employer Name
INSTRUCTIONS: You, the employee, must complete this enrollment form in full or it will be returned to you resulting in a delay in
processing. You are solely responsible for its accuracy and completeness. If waiving coverage, please complete Section H.
Effective Date
New Hire
Change of coverage
Employee Termination
COBRA/State Continuation for:
Employee
Dependent
Rehire/ Reinstatement
Add Spouse/Dependent Child
Remove Spouse/
Dependent Child
Length of Continuation:
New Group Enrollment
Name Change
Date of Hire
18
36
Other
Cancel Coverage
Late Enrollment
Other
Original Qualifying Event Date
Other
A. Coverage Selection –
Please print clearly, using black ink. (Shaded sections for Employer/Aetna Use Only)
Reason
Control/Group No.
Suffix
Account
Plan No.
Class Code
Control/Group No.
Suffix
Account
Plan No.
Control/Group
Suffix
Account
Plan No.
No.
1. Medical - Check one.
2. Dental - Check one.
3. Life and Disability
Standard Plans:
Basic Life/AD&D Ultra™
Aetna HMO Open Access –
Aetna Dental™ Plan – Plan Option
Plan Option
Optional Dependent Life
Freedom of Choice:
Aetna HMO Gatekeeper –
Short Term Disability
Plan Option
Managed Dental or
PPO
Life & Disability Packaged Plan
Aetna POS Open Access –
Out-of-State PPO Plan
Beneficiary Designation - Full Name (First, Middle, Last)
Plan Option
Voluntary Plans:
Aetna Managed Choice Open Access –
Aetna Dental™ Plan – Plan Option
Plan Option
Beneficiary Social Security Number
Freedom of Choice:
Aetna PPO –
Managed Dental or
PPO
Plan Option
Out-of-State PPO Plan
Relationship to Employee
Before today, were you covered under this employer’s dental
plan?
Yes
No
B. Employee Information -
Must be completed by the employee.
Social Security Number
Last Name, First Name, M.I.
Job Title
Home Telephone
Primary Language Spoken
(Optional)
Home Address
Apt. No.
City, State
ZIP Code
Work Address
City, State
ZIP Code
Work Telephone
Salary
No. of Hours Worked Per Week Check One
No. of Dependents Including
Spouse
$
Full-Time
Part-Time
Hourly
Weekly
Monthly
C. Individuals Covered -
List individuals for whom you are enrolling or adding/changing/removing coverage. Insert additional sheets if necessary.
Sex
Birthdate
Coverage
PCP Provider
Name (Last, First, M.I.)
M/F
Social Security Number
Relationship
(MM/DD/YYYY)
Status
Election
ID Number
Employee
Single
Married
Medical
Divorced
Windowed
Dental
Legally Separated
Life/Dis
Spouse
Different Last Name
Medical
Other
Dental
Life
Child
Child
Different Last Name
Medical
Stepchild
Dental
Lives at another address
Other
Life
Full-Time Student (19+)
Disabled (19+)
Child
Child
Different Last Name
Medical
Stepchild
Lives at another address
Dental
Other
Full-Time Student (19+)
Life
Disabled (19+)
D. Race/Ethnicity – Optional
(This information is designed for the purpose of data collection and will not be used for determining eligibility, rating or claim payment.)
Employee
Child
White – 01
African American or Black – 02
White – 01
African American or Black – 02
1.
3.
Hispanic or Latino – 03
Asian – 04
Other – 05
Hispanic or Latino – 03
Asian – 04
Other – 05
Spouse
Child
White – 01
African American or Black – 02
White – 01
African American or Black – 02
2.
4.
Hispanic or Latino – 03
Asian – 04
Other – 05
Hispanic or Latino – 03
Asian – 04
Other – 05
1
GR-67834-1 (12-07)
FL-SGB
R-POD H
NOTE: Before submitting this completed form to your employer, you may wish to protect the confidentiality of your
health information by taping or stapling the form so that pages 2 and 3 are not visible.
Florida Small Group Business (2 - 50 Eligible Employees)
Employee Enrollment/Change Form
Life, Accidental Death & Dismemberment, Disability, Aetna Managed Choice, and Aetna PPO plans are underwritten by Aetna Life
Insurance Company. Aetna HMO and Aetna POS plans are underwritten by Aetna Health Inc. Dental plans are provided or
Member Aetna ID Number (if available)
administered by Aetna Life Insurance Company.
Employer Name
INSTRUCTIONS: You, the employee, must complete this enrollment form in full or it will be returned to you resulting in a delay in
processing. You are solely responsible for its accuracy and completeness. If waiving coverage, please complete Section H.
Effective Date
New Hire
Change of coverage
Employee Termination
COBRA/State Continuation for:
Employee
Dependent
Rehire/ Reinstatement
Add Spouse/Dependent Child
Remove Spouse/
Dependent Child
Length of Continuation:
New Group Enrollment
Name Change
Date of Hire
18
36
Other
Cancel Coverage
Late Enrollment
Other
Original Qualifying Event Date
Other
A. Coverage Selection –
Please print clearly, using black ink. (Shaded sections for Employer/Aetna Use Only)
Reason
Control/Group No.
Suffix
Account
Plan No.
Class Code
Control/Group No.
Suffix
Account
Plan No.
Control/Group
Suffix
Account
Plan No.
No.
1. Medical - Check one.
2. Dental - Check one.
3. Life and Disability
Standard Plans:
Basic Life/AD&D Ultra™
Aetna HMO Open Access –
Aetna Dental™ Plan – Plan Option
Plan Option
Optional Dependent Life
Freedom of Choice:
Aetna HMO Gatekeeper –
Short Term Disability
Plan Option
Managed Dental or
PPO
Life & Disability Packaged Plan
Aetna POS Open Access –
Out-of-State PPO Plan
Beneficiary Designation - Full Name (First, Middle, Last)
Plan Option
Voluntary Plans:
Aetna Managed Choice Open Access –
Aetna Dental™ Plan – Plan Option
Plan Option
Beneficiary Social Security Number
Freedom of Choice:
Aetna PPO –
Managed Dental or
PPO
Plan Option
Out-of-State PPO Plan
Relationship to Employee
Before today, were you covered under this employer’s dental
plan?
Yes
No
B. Employee Information -
Must be completed by the employee.
Social Security Number
Last Name, First Name, M.I.
Job Title
Home Telephone
Primary Language Spoken
(Optional)
Home Address
Apt. No.
City, State
ZIP Code
Work Address
City, State
ZIP Code
Work Telephone
Salary
No. of Hours Worked Per Week Check One
No. of Dependents Including
Spouse
$
Full-Time
Part-Time
Hourly
Weekly
Monthly
C. Individuals Covered -
List individuals for whom you are enrolling or adding/changing/removing coverage. Insert additional sheets if necessary.
Sex
Birthdate
Coverage
PCP Provider
Name (Last, First, M.I.)
M/F
Social Security Number
Relationship
(MM/DD/YYYY)
Status
Election
ID Number
Employee
Single
Married
Medical
Divorced
Windowed
Dental
Legally Separated
Life/Dis
Spouse
Different Last Name
Medical
Other
Dental
Life
Child
Child
Different Last Name
Medical
Stepchild
Dental
Lives at another address
Other
Life
Full-Time Student (19+)
Disabled (19+)
Child
Child
Different Last Name
Medical
Stepchild
Lives at another address
Dental
Other
Full-Time Student (19+)
Life
Disabled (19+)
D. Race/Ethnicity – Optional
(This information is designed for the purpose of data collection and will not be used for determining eligibility, rating or claim payment.)
Employee
Child
White – 01
African American or Black – 02
White – 01
African American or Black – 02
1.
3.
Hispanic or Latino – 03
Asian – 04
Other – 05
Hispanic or Latino – 03
Asian – 04
Other – 05
Spouse
Child
White – 01
African American or Black – 02
White – 01
African American or Black – 02
2.
4.
Hispanic or Latino – 03
Asian – 04
Other – 05
Hispanic or Latino – 03
Asian – 04
Other – 05
1
GR-67834-1 (12-07)
FL-SGB
R-POD H
E. Dependent Information
Does any dependent listed in Section C live at another address?
Yes
No
If any dependent's last name differs from yours, explain the circumstances.
If Yes, who and what address?
F. Other Insurance
Does anyone enrolling on this enrollment form have current or prior coverage?
Yes
No
Proof of coverage must accompany this enrollment form for pre-existing condition credit and if an employee is waiving
Failure to provide Proof of Prior Coverage may subject you or a family
coverage. Acceptable forms of proof are:
member to the full pre-existing conditions limitation with no credit for
1. Certificate of Creditable Coverage from prior carrier, or
prior coverage. You may request a Certificate of Creditable Coverage
2. Copy of ID card or most recent payroll stub showing medical coverage deduction, or
from your prior carrier.
3. Copy of most recent medical premium bill from prior carrier.
Name of Covered Individual
Carrier Name
Group Number
Start Date
Termination Date
Health
Dental
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
G. Medicare Information
End-Stage Renal
Name of Person
Medicare Part A
Medicare Part B
Medicare Part D
Over Age 65
Disability
Disease Eff Date
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
H. Declination/Waiver of Coverage
- Check all that apply.
Print Employee Name
I understand I am eligible to apply for this coverage through my employer;
however, I am waiving coverage as noted below.
Reason for declining coverage (If applicable attach front/back of your health ID card):
Employee
Medical
Dental
Life
Disability
Covered by spouse’s group coverage - Carrier Name and ID number:
Spouse
Medical
Dental
Life
Child(ren)
Medical
Dental
Life
Enrolled in other insurance (check applicable box):
Medicare
TRICARE
CHAMPVA
Military
Individual
COBRA
Retiree
Other
Carrier Name and ID number:
Spouse covered by employer’s group coverage
Do Not Want
I certify I have been given the right to apply for this coverage; however, I am waiving coverage as noted above. By declining this group coverage I acknowledge that
myself and/or my dependents may have to wait until the plan's next anniversary date to be enrolled for group coverage. Pre-existing conditions, when enrolled in
this plan, may not be covered for twelve months.
Please sign here ONLY if you are declining coverage for yourself and/or dependent(s).
Date (Month/Day/Year)
X
Employee Signature
2 - 9
I. Health Questionnaire for Groups Enrolling
Eligible Employees
(or 2 - 50 if enrolling for life above the Guarantee Issue amount) and All
New Enrollees for Existing Groups with 2-50 Eligible Employees. All new business groups do not need to complete this section if they are eligible to complete
the Group Medical Questionnaire.
Health History for Individuals and Their Dependents.
The following information is confidential and will not be seen by or given to your employer.
• ALL of the questions must be answered by you or your application will be returned.
• Incomplete applications may delay the effective date of your coverage.
To the best of your knowledge and belief, in the past twenty-four (24) months, has any person listed on the application been
diagnosed with, treated for, or had treatment recommended by a licensed member of the medical profession for any of the
following conditions listed below?
Yes No
1. Heart attack, heart murmur, stroke, chest pain, high blood pressure, anemia, varicose veins or other disorders of the heart, blood,
blood vessels or high cholesterol? ...................................................................................................................................................................
2. Ulcer, colitis, gallstones or any other disorder of the stomach, intestines, rectum, pancreas, liver or Hepatitis B/C?......................................
3. Cancer, cyst or tumor? ......................................................................................................................................................................................
4. Disorders of the kidneys, adrenal glands, thyroid gland, urinary system, male or female organs, infertility, menstrual dysfunction or
sexually transmitted disease (except AIDS/ARC)? ...........................................................................................................................................
5. Asthma, emphysema, tuberculosis or any other disorders of the lungs or respiratory system? .......................................................................
6. Migraines, fainting spells, epilepsy, mental or nervous conditions, depression, paralysis or any disorder of the brain or nervous system?
If epileptic, date of last seizure:
/
/
(month/day/year) ........................................................................................................
7. Lupus, arthritis, back trouble or any other disorder of the joints, muscles or bones, including prosthetic device or implants? ........................
8. Any physical deformity, defect or congenital problem?.....................................................................................................................................
9. Alcoholism, other drug or substance abuse, including use of any illegal or controlled drugs, or been advised to seek treatment for
the same?..........................................................................................................................................................................................................
Continued on next page
IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS ABOVE YOU MUST COMPLETE SECTION K ON THE FOLLOWING PAGE.
2
GR-67834-1 (12-07)
FL-SGB
2 - 9
I. Health Questionnaire for Groups Enrolling
Eligible Employees
(Continued)
Yes No
10. Diabetes? If Yes, list date of diagnosis:
/
/
(month/day/year)
Insulin dependent
Non-insulin dependent ......
11. a. Is any female to be covered currently pregnant? If Yes, list due date:
/
/
(month/day/year) ......................................
b. Have there been any complications thus far? ..............................................................................................................................................
c. Are multiple births expected? ......................................................................................................................................................................
d. If you are a male listed on this application, are you expecting a child with anyone, even if the mother is not listed on this application?....
12. Has any applicant taken any prescribed medications in the past 12 months? If Yes, list below....................................................................
13. Has any applicant been advised to undergo further testing, surgery or treatment?..........................................................................................
14. Has any applicant been a patient in a hospital, clinic, surgical center, sanatorium or medical facility as an outpatient or inpatient
(excluding childbirth)? .......................................................................................................................................................................................
15. Do you or your spouse use tobacco products, including cigarettes, pipe, cigars, or chewing tobacco? ..........................................................
If Yes, check applicable boxes:
Employee
Spouse
16. Has any applicant had any medical condition not listed on this application?....................................................................................................
Has any person listed on this enrollment form been tested positive for exposure to the HIV infection or been diagnosed as having ARC or
AIDS caused by the HIV infection or other sickness or condition derived from such infection? .............................................................................
IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS ABOVE (EXCEPT LAST QUESTION), YOU MUST COMPLETE SECTION J BELOW.
If you are providing additional sheets, check here
and insert the sheets before sealing this Enrollment form.
J. Health Questionnaire - Details for "Yes" Responses in Section I.
IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS IN SECTION I (EXCEPT LAST QUESTION IN SECTION I), YOU MUST COMPLETE THE FOLLOWING
TO THE BEST OF YOUR KNOWLEDGE AND BELIEF.
Please provide us with FULL DETAILS for each "Yes" answer to any condition(s) checked in Section I. In addition, please give details below of last doctor
visit and/or physical examination for ALL family members listed regardless of the date or reason. (Insert additional sheets if necessary.)
Question
Date of
Date Treatment
Still Taking
Number
Name of Individual
Condition/Diagnosis Date
Onset
Ended
Medication Prescribed
Dosage
Medication
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If you are providing additional sheets, check here
and insert the sheets before sealing this Enrollment form.
3
GR-67834-1 (12-07)
FL-SGB
Conditions of Enrollment
On behalf of myself and the dependents listed on the reverse side:
1. I acknowledge that by enrolling in the following plans, coverage is provided by the following entities (collectively referred to
as “Aetna”):
● Aetna HMO plans: Aetna Health Inc.
● Aetna POS plans: Aetna Health Inc.
● Life, Accidental Death & Dismemberment, disability, dental and all other health coverages: Aetna Life Insurance
Company.
2. I understand and agree that my employer’s application will determine coverage and that there is no coverage unless and
until both the eligible employee enrollment form and employer applications have been accepted and approved by Aetna.
For life and disability coverages: I understand that the effective date of insurance for myself or for any of my
dependents is subject to my being actively at work on that date and that the effective date of insurance for any of my
dependents is also subject to the dependent health condition requirements of the benefit plan. Further, I understand that
any insurance subject to evidence of good health or medical information will not become effective until Aetna gives its
written consent.
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”), including pharmacies or pharmacy database benefit managers to give to Aetna or its agent information
concerning the medical history, prescription utilization history, services or treatment provided to anyone listed on this
Enrollment/Change Request form, including those involving mental health and substance abuse. 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. This authorization will remain valid for the term of the coverage and for 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.
6. I understand and agree that, with certain exceptions described in the plan documents, HMO and Managed Dental plans
only provide coverage for referred benefits, and that, in order to be covered, services must be performed either by a
participating primary care physician, primary care dentist, or by the participating specialist, hospital, pharmacy, dentist, or
other provider as authorized by a referral from a participating primary care physician.
7. To the best of my knowledge and belief, I represent that all information supplied in this form is true and complete. On
behalf of myself and the eligible persons listed herein, I acknowledge that I have read and understand this form in its
entirety.
I represent that all information supplied in this form is true and complete. I have read and agree to the Conditions of Enrollment
and Misrepresentation on this Florida Small Group Business (2 - 50 Eligible Employees) Employee Enrollment/Change Form.
I understand that, in the event I fail to sign this form within 31 days after the above transaction request or for any reason Aetna
does not receive notice of the above transaction request within a reasonable time following the event, my and my dependents’
eligibility may be affected.
I am employed by the employer shown on Page 1, and I am working full time at least 25 hours per week for this employer at the
regular place of business.
Misrepresentation: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a
statement of claim or an application containing any false, incomplete or misleading information is
guilty of a felony of the third degree.
Employee Signature
Employee E-mail Address (optional)
Date (Month/Day/Year)
X
4
GR-67834-1 (12-07)
FL-SGB

Download Form GR-67834-1 Enrollment/Change Form - Aetna - Florida

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