Form Gr-67971-7 - Dental Enrollment Change Request - Aetna
Download a blank fillable Form Gr-67971-7 - Dental Enrollment Change Request - Aetna in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Gr-67971-7 - Dental Enrollment Change Request - Aetna with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2*
The parties of a Civil Union, in line with New Hampshire Law, shall be entitled to all of the
Dental Enrollment/Change Request
rights, and subject to all of the obligations and responsibilities as those parties that are
joined together in legal marriage. Wherever the term "spouse" is used in this Plan it shall
Aetna Life Insurance Company
be read to include a Civil Union Partner.
Employer Name - Full Name of Business or Organization
Control
Suffi x
Account
Plan Number
Employer Group Information:
(To Be Completed by Employer)
Employer Address (Street, City, State, ZIP Code) - Primary Location of Business or Organization
A. Type of Activity -
Employee Completes Sections A - E.
Please Print Clearly.
Instructions: Refer to the instructions
Enrollment
Change
Remove or Terminate
Continuation of Coverage, i.e., COBRA, State
- Check one.
- Check all that apply.
- Check all that apply.
- Not all options
Date of Event
on the back before completing this form.
Add Spouse *
Remove Spouse *
are available. Contact Employer for available options.
New Enrollee/Subscriber
Rehire/Reinstatement
Coverage For:
Employee
Dependents
Effective Date
/
/
You, the employee, must complete this
Add Dependent Child
Date of Rehire/Reinstatement
Remove Dependent
Effective Date
Length of Continuation (months):
18
36
Other
/
/
application in full or it will be returned
Child
Name Change
Reason
/
/
/
/
29 -
Attach disability determination from the Social Security Admin.
to you resulting in a delay in process-
Employee Withdrawal/
Other
Reason
Date of Hire
Date of Loss of Coverage
Date of Qualifying Event
ing. You are solely responsible for its
Termination
Control/Suffi x/Acct/Plan
/
/
accuracy and completeness.
/
/
Cancel Coverage
/
/
B. Employee Information
C. Plan Options -
Your selection must be offered by your employer.
Primary Language Spoken
Social Security Number
Last Name, First Name, M.I.
Check One:
Indemnity Dental
Dental EPP
FOC/Indemnity
Employee Home Address
Telephone Numbers
Employee Status
DentalFund/HealthFund
DMO
®
FOC/PPO
Number, Street, Apt
Home
(
)
Active
Dental PPO
FOC/DMO
Retired
Work
(
)
City, State
ZIP Code
D. Individuals Covered
- List individuals for whom you are adding/changing/removing coverage.
Attach sheet to list additional children.
* Provide details for "Yes" responses below.
Check this box if you are refusing coverage for your dependents.
(A)dd
Birthdate
Late
Prior
Other
Currently
Handi-
Student
Name (First, Middle Initial, Last)
Sex
Social Security Number
Relationship
Primary Dentist
Current
(C)hange
Entrant
Insur.
Dental
Covered by
capped
Code
Patient
(Explain difference in last names in Special Remarks.)
(If dependent has no SSN, write "None")
Offi ce ID Number
M F
MM
DD
YYYY
(R)emove
Coverage
Plan
Medicare
Yes
*
Yes
*
*
Yes
Yes
Yes
Yes
Yes
/
/
Self
N/A
N/A
/
/
/
/
/
/
/
/
3. Does any dependent listed above live at a different address than the employee? If "Yes," who and what address?
1. If "Yes" to Prior Insurance Plan above, provide effective dates, name & policy number of insurance carrier, dental plan
Yes
No
or other source and your Member Identifi cation Number.
Special Remarks
2. If "Yes" to Other Dental Coverage and/or Currently Covered by Medicare above, provide effective dates, name &
policy number of insurance carrier, dental plan or other source and your Member Identifi cation Number.
E. Employee Signature
By checking this box you agree to use Aetna Navigator, Aetna's member self-service website, for all future printed materials.
Employee Signature - Required
I represent that all information supplied in this form is true and complete to the best of my knowledge and/or belief. I have read and agree to
X
the Conditions of Enrollment on the reverse side of this Enrollment/Change Request form. I understand that in the event I fail to sign this form
within 31 days after the above transaction request or that for any reason Aetna does not receive notice of the above transaction request within a
Date
E-Mail Address
/
/
reasonable time following the event, my and my dependents' eligibility may be affected.
Please make a copy for your records.
visit us at
GR-67971-7 (5-08)
NH V1 R-POD C
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business