Fillable Form Gr-69068-5 - Aenta Enrollment Form (Page 4 of 4) in pdf

Conditions of Enrollment

On behalf of myself and the dependents listed, I agree to or with the following:

1. I acknowledge that by enrolling in an Aetna plan(s), coverage is provided by Aetna Life Insurance Company (referred to as “Aetna”). Vision

insurance plans are underwritten by Aetna Life Insurance Company (Aetna). Certain claims administration services are provided by First American

Administrators, Inc. and certain network administration services are provided through EyeMed Vision Care, LLC (“EyeMed”).

2. I understand 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 application have been accepted and approved by Aetna.

3. I understand and agree that: this enrollment 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”), including pharmacies or pharmacy database benefit

managers to give 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, excluding drug and alcohol records and psychotherapy notes. 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. This authorization will remain valid no longer than 24 months. I understand that I am entitled, as is any authorized

representative that I may designate, to receive a copy of this authorization upon request and that a photocopy is as valid as the original. This

authorization is voluntary. However, I understand that if I refuse to sign this authorization form, my ability to enroll in the plans described above may be

affected. I have the right to revoke this authorization in writing to Aetna at any time except to the extent that my information has already been used or

disclosed in reliance on this authorization. However, because this information is essential to the administration of the plans, I understand that my

revocation of this authorization may result in a contest of enrollment in the plans described above.

4. The plan certificate of coverage will determine the rights and responsibilities of member(s). It 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

and Aetna Specialty Pharmacy

, all participating providers and

vendors are independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, and Aetna Specialty

Pharmacy, LLC, are subsidiaries 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, 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 dentist or by the participating dentist or other

provider as authorized by a referral from a participating primary care dentist.

7. This form is attached to and forms part of the policy and certificate, and may be used to contest the insurance. made by the insured relating to their

insurability with respect to which such statement was made only if a copy

8. The validity of individual coverage may be contested within the first two years during the insured’s lifetime using written, signed statements has

been furnished to the insured or their beneficiary. The policy is incontestable after two years other than non-payment of premiums.

Misrepresentation

9. 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated

value of the claim for each such violation.

I represent that to the best of my knowledge and belief all information supplied in this form is true and complete. I have read and agree to the

Conditions of Enrollment and Misrepresentation on this New York Small Group Business Employee Enrollment/Change Form. I understand that if I do

not sign this form within 31 days from the date first eligible or 31 days of the qualifying life event (i.e., marriage, divorce, newborn child, adoption, loss of

spousal coverage, etc.) I will be considered a late enrollee and the effective date of coverage for me and my dependents may be affected. I am

employed by the employer shown on Page 1, and I am working full time at least 20 hours per week for this employer at the regular place of business. I

authorize deductions from my earnings for any contributions required for coverage and I agree to make any necessary payments as required for

coverage.

If you wish to receive documents electronically, please refer to Aetna Navigator

Please sign here ONLY if you are enrolling in coverage for yourself

Employee E-mail Address

Date (Month/Day/Year)

and/or dependent(s).

Employee Signature

Spouse/Domestic Partner Signature

Date (Month/Day/Year)