Fillable Form Gr-69209-14 - Ohio Employee Enrollment/change Form

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 the following plans, coverage is provided by the following entities (collectively referred to as “Aetna”):

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Aetna HMO plans: Aetna Health Inc.

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Aetna Health Network Option plans: Aetna Health Inc. and/or Aetna Health Insurance Company

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Aetna Savings Plus plans: Aetna Health Inc., Aetna Life Insurance Company and Aetna Health Insurance Company

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Aetna PPO and Indemnity plans: Aetna Life Insurance Company

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Aetna Vision

Preferred plans: Aetna Life Insurance Company; certain claims adjudication and other administrative services are provided by

First American Administrators, Inc. (an affiliate of EyeMed Vision Care, LLC) and/or its affiliates

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Dental and other health coverages: Aetna Life Insurance Company.

2. I understand and agree that my employer’s application will determine coverage and that there is no coverage until Aetna has approved both my

employee enrollment form and the employer applications.

3. I understand and agree that this Enrollment / Change Form may be transmitted to Aetna or its agent by my employer or its agent. I authorize any

physician, other health care professional, hospital or any other health care organization (“providers”), including pharmacies or pharmacy database

benefit managers, to give to Aetna or its agent information concerning the medical history, prescription utilization history, services or treatment

provided to anyone listed on this Enrollment / Change Form, including those involving mental health and substance abuse. 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. I have discussed the terms of this authorization with my spouse / domestic partner and competent adult

dependents, and I have obtained their consent to those terms. Authorizations signed for the purpose of collecting information in connection with this

application for an insurance policy, a policy reinstatement or a request for a change in policy benefits shall remain valid for thirty (30) months from

the date it is signed. Authorizations signed for the purpose of collecting information in connection with a claim for benefits shall remain valid for the

term of this coverage or for so long as allowed by law. I understand that I am entitled 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 medical 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 cancellation of my enrollment in the medical

plans described above.

4. The plan documents will determine the rights and responsibilities of member(s) and will govern in the event they conflict with any benefits

comparison, summary or other description of the plan.

and Aetna Specialty Pharmacy

, all participating providers and

5. I understand and agree that, with the exception of Aetna Rx Home Delivery

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, HMO and 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 physician, primary care dentist, or by

the participating specialist, hospital, pharmacy, dentist, or other provider as authorized by a referral from a participating primary care physician.

I represent that all information supplied in this form is true and complete. I have read and agree to the conditions of enrollment and misrepresentation on

this Employee Enrollment / Change Form.

I understand that in the event I fail to sign this form within 31 days after the above transaction request or for any reason Aetna does not receive notice of

the above transaction request within a reasonable time following the event, my eligibility and my dependents’ eligibility may be affected.

I am employed by the employer shown on page 1. I am working full time or at least 25 hours or more a 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 required

for coverage.

Misrepresentation: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a

claim containing a false or deceptive statement is guilty of insurance fraud.

If you wish to receive documents online, please visit your secure member account at

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

Employee email

Date (Month/Day/Year)

and/or dependent(s).

Employee signature (required)

GR-69209-14 (4-16)