Fillable Form Gr-67834-2 - Aetna Texas Employee Enrollment/change Form (Page 4 of 4) in pdf

Conditions of Enrollment

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 the following plans, coverage is provided by the following entities (collectively referred to as

“Aetna”):

● Aetna HMO Plan: Aetna Health Inc.

● Aetna Quality Point-of-Service/Point-of-Service Plans: Aetna Health Inc. (In-Network) and Aetna Health Insurance Company,

(Out-of-Network)

● Aetna Dental DMO: Aetna Dental Inc.

● Life, 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 and employer applications have been accepted by Aetna. Even if this enrollment form is accepted, any

intentional misstatement or omission of material fact may result in future claims being denied.

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 Form 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 to Aetna

or its agent information concerning the medical history, services or treatment provided to anyone listed on this Enrollment/Change

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/domestic partner 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 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 DMO 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. I understand and agree that, as described in the plan documents, when enrolled for medical coverage in other than an HMO plan,

any pre-existing conditions for my spouse/domestic partner, dependents or myself may not be covered for 12 months. NOTE: If

your Plan contains a pre-existing conditions provision, the pre-existing conditions exclusion and limitation will not apply to a person

under 19 years of age.

Misrepresentation

8. Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application

for insurance or statement of claim containing any intentional misrepresentation of material fact or conceals, for the purpose of

misleading, information concerning any fact material thereto may commit a fraudulent insurance act, which may be a crime and

may subject such person to criminal and civil penalties.

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 Texas Small Group Business 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, usually 30 hours per week, for this employer at the regular place of

business.

If you have questions concerning the benefits and services that are provided by or excluded under this Agreement, please contact a

Member Services representative at 1-800-323-9930 before signing this form.

Employee Signature

Employee E-mail Address (optional)

Date (Month/Day/Year)

Employer Signature

Date (Month/Day/Year)

GR-67834-2 (3-11)

Form Gr-67834-2 - Aetna Texas Employee Enrollment/change Form Page 4

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