Form Gr-67971 - Dental Enrollment Change Request Aetna (Page 2 of 2) in pdf

Instructions

Conditions of Enrollment

Employer

Applicant Acknowledgments and Agreements

•

Complete the Employer Group Information at the top of the form.

On behalf of myself and the dependents listed on the reverse side, I agree to or with the following:

•

Complete Section F - Employer Verification in the lower right corner of the form.

1. * I acknowledge that by enrolling in the following plans coverage is provided or administered by the following entities

•

Employer must complete this section for all new enrollments or coverage changes.

(collectively referred to as "Aetna"):

•

Employer must sign and date the Enrollment/Change Request in order for it to be processed.

• Aetna DMO, Aetna Dental PPO, Dental EPP, Aetna HealthFund/Aetna DentalFund, and Aetna Indemnity Dental: Aetna

Life Insurance Company

Employee -

Complete Sections A - E.

• In the states of AZ, CA, GA, MD, MO, NC, NJ and TX, Aetna DMO, Advantage and Basic plans may also be provided by

one of the following: Aetna Dental of California Inc., Aetna Dental Inc. (NJ), Aetna Dental Inc. (TX), Aetna Health Inc.,

Section A - Type of Activity:

•

or Aetna Health Inc. (AZ).

Check box(es) indicating reason(s) for submitting this Enrollment/Change Request. Provide Effective Date(s) and

Date of Event(s) where requested.

2. I authorize deductions from my earnings for any contributions required for coverage and I agree to make any necessary

payments as required for coverage.

Section B - Employee Information:

•

Complete all information in order for your Enrollment/Change Request to be processed.

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

agent. I authorize any physician, other healthcare professional, hospital or any other healthcare organization ("Providers")

Section C - Plan Option:

•

to give Aetna or its agent information concerning the medical history, services or treatment provided to anyone listed on this

Select only an option offered by your employer.

Enrollment/Change Request form, including those involving mental health, substance abuse and HIV/AIDS. I further

Section D - Individuals Covered:

authorize Aetna to use such information and to disclose such information to affiliates, providers, payors, other insurers, third

•

Add/Change/Remove - Use "A", "C", or "R" to indicate whether you are adding, changing or removing coverage for

party administrators, vendors, consultants and governmental authorities with jurisdiction when necessary for my care or

an individual.

treatment, payment for services, the operation of my health plan, or to conduct related activities. I have discussed the terms

•

Print your full name along with the name(s) of your dependent(s), if applicable. Indicate Relationship Code, Sex,

of this authorization with my spouse and competent adult dependents and I have obtained their consent to those terms. I

Birthdate, and Social Security Number for each individual listed.

•

understand that this authorization is provided under state law and that it is not an "authorization" within the meaning of the

Relationship Code - Use ONLY: H=Husband, W=Wife, N=Divorced Spouse, S=Son, D=Daughter, Y=Sponsored

federal Health Insurance Portability and Accountability Act. This authorization will remain valid for the term of the coverage

Male, X=Sponsored Female. If the dependent is NOT a biological or legally adopted child, please indicate

and so long thereafter as allowed by law. I understand that I am entitled to receive a copy of this authorization upon request

relationship to employee in Special Remarks.

•

and that a photocopy is as valid as the original.

Late Entrant - If you are not enrolling within your employer's eligible enrollment period, check "Yes".

•

If you or your dependent(s) were covered under your employer's or other prior insurance plan, check the "Yes"

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

box(es) and provide name and policy number of insurance carrier, dental plan or other source in the space provided.

any benefits comparison, summary or other description of the plan.

•

If you or your dependent(s) have other Dental Coverage, check the "Yes" box(es) and provide name and policy

5. I understand and agree that with the exception of Aetna Rx Home Delivery, all participating providers (including all

number of insurance carrier, dental plan or other source in the space provided.

participating primary care dentists) and vendors are independent contractors and are neither agents nor employees of

•

If a dependent is Handicapped and financially dependent, check "Yes" and provide proof of handicapped status

Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be

from the attending physician.

guaranteed and provider network composition is subject to change. Notice of the change shall be provided in accordance

•

If a dependent is a Student, check "Yes". Refer to your Summary Coverage for plan definitions. Aetna may

with applicable state law.

request that you provide proof from the educational institution.

•

Misrepresentation

Primary Dentist Office ID Number - Locate the office ID number for the primary dentist from the appropriate provider

directory or from "DocFind

", Aetna's online provider directory at "

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance

•

If you are a current patient, please check the "Yes" box under Current Patient.

or statement of claim containing any materially false information or conceals, for the purpose of misleading, information

•

concerning any fact material thereto may have violated state law.

Optional - Indicate the Race/Ethnicity for yourself and your dependents by checking the appropriate box(es). If

your Race/Ethnicity is other than the selections listed, please check the "Other" box and print the Race/Ethnicity

Attention Colorado Residents: An insurer/agent who knowingly provides false or misleading information to defraud a

for yourself and your dependents in the space provided.

Colorado claimant regarding insurance proceeds must be reported to the insurance division.

Section E - Employee Signature:

Attention Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a

•

Complete this section for all new enrollments or coverage changes.

statement of claim or any application containing any false, incomplete or misleading information is guilty of a felony of the third

•

Employee must sign and date the Enrollment/Change Request in order for it to be processed.

degree.

Section F - Employer Verification:

Attention Kentucky and Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance

•

Employer must complete this section for all new enrollments or coverage changes.

company or other person files an application for insurance or statement of claim containing any materially false information or

•

Employer must sign and date the Enrollment/Change Request in order for it to be processed.

conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,

which is a crime and subjects such person to criminal and civil penalties.

(7-03) GR-67971

Form Gr-67971 - Dental Enrollment Change Request Aetna Page 2

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