Form Gr-69209-14 - Ohio Employee Enrollment/change Form - Aetna Page 2
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5B. Coverage selection
Continued)
(
Control/Group number
Suffix
Account
Plan number
2. Dental
Yes
No
To enroll, enter the plan number and name below.
Non-voluntary plans – Plan number:
Plan name:
If FOC, choose:
DMO
or
PPO
®
Voluntary plans – Plan number:
Plan name:
If FOC, choose:
DMO
PPO
or
®
Before today, were you covered under this employer’s dental plan?
Yes
No
Creditable coverage is allowed for new members enrolling in voluntary takeover groups. New hires please see below if applicable:
New Hire selecting a Voluntary plan and your Aetna plan is a takeover group: Were you covered for 12 months under a dental plan within the
last 90 days that included both Preventive and Basic coverage? Discount dental and preventive only plans do not apply.
Yes
No
Control/Group number
Suffix
Account
Plan number
3. Vision
Aetna Vision
Preferred
Yes
No
SM
C. Individuals covered
– List individuals for whom you are enrolling or adding, changing or removing coverage. Add more sheets if needed.
NOTE FOR MEDICAL COVERAGE: While the Affordable Care Act mandates coverage of dependent children up to age 26, your plan may allow
coverage beyond age 26. Please refer to your plan documents or contact your benefits administrator.
Employee name (Last, first, middle initial)
Sex (M/F)
Add
1
Change
Remove
Birthdate (MM/DD/YYYY)
Status
Choosing coverage for :
Primary care physician
Current
(PCP) provider ID number
patient
Single
Married
Divorced
Medical
Dental
/
/
Yes
Widowed
Legally separated
Vision
Name (Last, first, middle, initial)
Sex (M/F) Social Security number
Add
Spouse
Domestic Partner
2
Change
Remove
Current
Birth date (MM/DD/YYYY)
Choosing coverage for:
PCP provider ID number
patient
Medical
Dental
Vision
/
/
Yes
Sex (M/F) Social Security number
Add
Name (Last, first, middle initial)
Child
Stepchild
3
Change
Other
Remove
Status
Current
Birthdate (MM/DD/YYYY)
Choosing coverage for:
PCP provider ID number
patient
Different last name
Medical
Dental
Vision
/
/
Yes
Incapacitated
Sex (M/F) Social Security number
Add
Name (Last, first, middle initial)
Child
Stepchild
4
Change
Other
Remove
Status
Current
Birthdate (MM/DD/YYYY)
Choosing coverage for:
PCP provider ID number
patient
Different last name
Medical
Dental
Vision
/
/
Yes
Incapacitated
Sex (M/F) Social Security number
Add
Name (Last, first, middle initial)
Child
Stepchild
5
Change
Other
Remove
Birthdate (MM/DD/YYYY)
Status
Choosing coverage for:
PCP provider ID number
Current
patient
Different last name
Medical
Dental
Vision
/
/
Incapacitated
Yes
Sex (M/F) Social Security number
Add
Name (Last, first, middle initial)
Child
Stepchild
6
Change
Other
Remove
Birthdate (MM/DD/YYYY)
Status
Choosing coverage for:
PCP provider ID number
Current
patient
Different last name
Medical
Dental
Vision
/
/
Incapacitated
Yes
2
OH
GR-69209-14 (4-16)
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