Form Nj Hint - New Jersey Enrollment/change Request - Aetna Page 4
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4Conditions of Enrollment – Applicant Acknowledgements and Agreements
On behalf of myself and the dependents listed in this Enrollment/Change Request form, I acknowledge that:
1. I authorize any physician or medical professional, hospital, clinic or other medical care institution, carrier, consumer reporting agency, and any employer
to give Aetna Health Inc. and/or Aetna Life Insurance Company, or any consumer reporting agency acting on behalf of Aetna Health Inc. and/or Aetna
Life Insurance Company, information pertaining to employment, other health coverage, and medical advice, treatment or supplies for any physical or
mental condition relevant to me or a minor dependent applying for coverage. I agree that this authorization shall be valid for 30 months from the date I
sign this Enrollment/Change Request form, unless revoked at an earlier date.
2. I agree that, if I revoke this authorization before it expires, such revocation shall not affect any action that Aetna Health Inc. and/or Aetna Life Insurance
Company has taken in reliance on the authorization.
3. I understand I may receive a copy of this authorization if I request one.
4. I agree Aetna Health Inc. and/or Aetna Life Insurance Company will provide coverage in accordance with the terms of the contract for the group plan.
5. I agree that the provision of coverage and benefits is contingent upon payment of premiums and may be terminated in accordance with the terms of the
group plan if premiums are not paid timely. I authorize my Employer to withhold payments from my wages as contribution to the premium, as
appropriate.
Instructions
Employer:
You must complete the Employer Group Information and Sections A and I in order for this application to be processed.
Employee:
You must complete Sections B through H.
•
Please PRINT except when a signature is requested.
Qualifying Events
•
If a dependent is disabled and you want to continue his or her coverage beyond
COBRA and NJSGC
age 26, you do not have to make a COBRA/NJSGC or Dependent Under 31
C1. Termination of job or reduction in hours.
election. Instead, select “Other” in Section A2, and attach proof of disability.
C2. Employee enrollment in Medicare (COBRA only)
•
For provider addresses, include the zip code plus the four digit extension.
C3. Divorce (COBRA/NJSGC); civil union dissolution (NJSGC)
•
You can obtain each provider’s correct name, address and 6-digit office ID number
C4. Death of employee
for the primary care physician from the appropriate directory. Indicate office ID
C5. Loss of dependent child status under the plan
number selection(s) on the form.
C6. Disability (occurring subsequent to another qualifying event)
•
You can obtain the provider’s NPI number by contacting the provider directly.
Providers with multiple office locations and individual providers who belong to more
than one practice or provider entity may have more than one NPI number. You
should confirm the correct NPI number for the specific provider and office location
where you will be seen by contacting the office directly.
•
To Add, Change, or Remove coverage for dependents over the limiting age,
but less than 31, Aetna Form HINT Supplemental Enrollment Information
Form Implementing P.L. 2005, c. 375, must be completed.
NJ HINT - Group
SGB GR-68900-25 (8-13) V2
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