Form Gr-68004-4 - Aetna Individual Medicare Supplement Plan Application (Page 6 of 8) in pdf

Applicant’s Name

Social Security Number

RELEASE AUTHORIZATION – PLEASE READ CAREFULLY BEFORE SIGNING

Please sign and date where indicated on this page. PLEASE MAKE A COPY FOR YOUR RECORDS

IT IS IMPORTANT THAT YOU READ AND UNDERSTAND THE FOLLOWING BEFORE YOU SIGN. By filing this

Application and applying for this coverage, I agree to or with the following:

1. Aetna may decline this Application if you do not qualify because you are not enrolled in Medicare Parts A and B. No

coverage comes into effect until Aetna approves this Application.

2. Coverage and benefits, once they come into effect, are contingent on a timely and accurate payment of premiums and

any other contribution provided in the plan documents. If premium payments are not paid on time and accurately,

coverage will be terminated. If terminated for nonpayment of premium, I may no longer be eligible to enroll in Aetna’s

Individual Medicare Supplement Plan.

Important Note: The Monthly Premium Rate(s) selected/calculated by the Applicant in Section[s] [5(c) and 6] will be

validated for accuracy by Aetna prior to approval of this Application. If Aetna determines that an incorrect Monthly

Premium Rate has been selected/calculated, the Applicant will be contacted by Aetna, the appropriate Monthly Premium

Rate will be assessed and the Applicant will be required to acknowledge acceptance of the corrected Monthly Premium

Rate prior to approval of this Application.

3. I authorize Aetna to request my medical records, any prescribed medication history and any other medical or

pharmaceutical information to process my Application and to make a decision on the approval or disapproval of my

Application. I authorize any physician, other healthcare professionals, hospital, clinics, labs, pharmacies, pharmacy

benefit managers or any other healthcare organization (“Providers”) that provided treatment or any other service to me to

disclose the information required by Aetna and described above to Aetna and/or its designated agents. I understand that

I may revoke this authorization at any time while Aetna is determining eligibility for the coverage requested. To do so, I

must notify Aetna in writing prior to the issuance of the policy. Revocation of this authorization will result in the closure of

my Application.

4. I understand that I am entitled to receive a copy of this Application upon request, and that a photocopy is as valid as the

original.

5. Providers are independent contractors and are not agents of Aetna.

6. Information on insurance agent/broker compensation is available from your agent.

7. I understand that 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 be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.

I UNDERSTAND THAT IF MY SIGNATURE/DATE DO NOT APPEAR AND/OR ARE NOT CURRENT AND/OR MY

ANSWERS ARE INCOMPLETE, my application will be declined.

I acknowledge receipt of a copy of “A Guide to Health Insurance for People with Medicare” and an Outline of Coverage, and

that I have made a copy of this Application.

Applicant’s Signature:

Application Date:

Power of Attorney or Legal Guardian Signature*:

* If Applicant is unable to sign, a court-appointed legal guardian or a designee authorized by state law must sign above.

Attach a copy of the document that designates this person as the Applicant’s representative.

PLEASE MAKE A COPY FOR YOUR RECORDS

Page 6 of 8

GR-68004-4 (4-11) NY

[C]

Form Gr-68004-4 - Aetna Individual Medicare Supplement Plan Application Page 6

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