Form Gr-69209-14 - Ohio Employee Enrollment/change Form - Aetna Page 3
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5D. Dependent information
List any dependent in Section C living at another address.
Name
Address
E. Coordination of benefits
Will you have other health insurance at the same time as this coverage?
Yes
No
If yes, will the Aetna coverage you’re applying for replace the coverage you have now?
Yes
No
Name of person
Carrier name
Name of person
Carrier name
F. Medicare information
End-stage
Medicare
Medicare
Medicare
Over
renal disease
Name of person
Part A
Part B
Part D
age 65
Disability
effective date
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
G. Declining coverage
– Check all that apply.
I understand I am eligible to apply for this coverage through my employer; however, I am declining the coverage I checked below:
Reason for declining coverage
Employee:
Medical
Dental
Parental group coverage
TRICARE / Military coverage
Vision
Spouse / domestic partner group
Individual coverage – On Exchange
Spouse / domestic
Medical
Dental
coverage
Individual coverage – Off Exchange
partner:
Medicare
Vision
Another group plan provided by
Medicaid
my employer
Retiree coverage
Do not want
Child(ren):
Medical
Dental
COBRA coverage
Other
Vision
Insurance through another job
I certify I have been given the right to apply for this coverage; however, I am declining coverage as noted above. By declining this group coverage, I
acknowledge that I and/or my dependents may have to wait until the plan's next anniversary date to be enrolled for group coverage.
Date (Month/Day/Year)
Please sign here ONLY if you are declining coverage for yourself and/or dependent(s).
X
I am declining coverage. Employee signature:
Please PRINT employee name:
H. Health questionnaire must be completed for all individuals enrolling for coverage.
Health history for you and your dependents. The following information is confidential and will not be seen by or given to your employer.
You or your dependents must answer ALL of the questions. Incomplete enrollment forms may delay the date your coverage starts.
Within the last five years, has anyone applying for coverage consulted with or received treatment from a doctor, psychiatrist,
1.
Yes
No
psychologist, or other practitioner or been diagnosed with any of the following conditions or disorders? (Check all that apply.)
a.
Diabetes
l.
Tumor / cyst / growth
w.
Arthritis / bone / joint / muscle / prosthetic device
b.
Infertility
m
Systemic or discoid lupus
x.
Mental / nervous / emotional / eating disorder
c.
Endocrine/
n.
Lung or respiratory
y.
Stroke / brain / neurological
metabolic
o.
Alcohol or drug use
z.
Transplant:
Recommended
Pending
Complete
d.
Pancreas
p.
Kidney / bladder / urinary
aa.
Advised to have
Tests,
Surgery,
Hospitalization or is
e.
Liver / hepatitis
q.
Circulatory / vascular
treatment needed, or
course of treatment not yet determined
f.
Immune system
r.
Digestive / stomach / intestinal
bb.
Cancer: Type:
Stage
g.
Blood disorder
s.
Central nervous system
Surgery
Chemo
Radiation
h.
Hemophilia
t.
Connective tissue disorder
cc.
Using:
Crutches
Walker
Wheelchair
i.
Epilepsy / seizure
u.
Pituitary / adrenal /
dd.
Other
j.
Heart
growth disorder
k.
Paralysis / paresis
v.
Birth defects / congenital
abnormalities
Continued on next page
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OH
GR-69209-14 (4-16)
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