Section A. Employee Information
Last Name, First Name, Middle Initial:
City, State:
ZIP Code:
Date of Hire:
Number of Hours Worked a Week:
Check One: Full Time 1099 Seasonal COBRA Part Time Retired Temporary Union
Employee Acknowledgement: I understand that it is fraud to file an application for coverage, an enrollment form or claim that contains materially false information knowingly and with intent to defraud. It is illegal to conceal, for the purpose of misleading, information concerning any material fact. A person who commits fraud or intentionally misrepresents material facts is subject to civil penalties and may be charged with a crime. If you commit fraud or intentionally misrepresent material facts, your coverage can be cancelled or your rated can be increased back to your effective date. If I become aware of any new information after I have completed this enrollment form but before the effective date that would change any answer on this form or make me report something not reported on this form, I agree to provide that information to Aetna as soon as possible.
Conditions of Enrollment: I understand and agree that my employer's application will determine coverage and that there is no coverage unless and until Aetna approves both this enrollment form and the employer application. I agree that my employer or its agent may send this enrollment form to Aetna. I authorize all my doctors, pharmacies, hospitals and other health care providers ("providers") to give Aetna any and all personal health information about me and others listed on this form. This authorization covers all health matters including those involving mental health, substance abuse and HIV/ AIDS. 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 and competent adult dependents and I have obtained their consent to those terms. This authorization will remain valid for the term of the coverage and so long thereafter 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.
Please sign here (Type your full name) ONLY if you are enrolling in coverage for yourself and/or dependents. Date: (Month/Date/Year)
Section D. Health Questionnaire (Continued)
Provide all details below for all "Yes" answers indicated above. How many questions did you answer "Yes" to?0 1 2 3 4 5 6 7 8
Question Number:
Enrollee Name:
Condition/Diagnosis:
Treatment: (Include surgery, hospitalized, durable medical equipment/supplies, etc.)
Medication Names: (Include those taken orally, injected, infused, topically, nasally, inhaled, etc.)
Dates Treated:
Is Treatment Ongoing? If yes, provide details of any current OR future treatment.
Question Number:
Enrollee Name:
Condition/Diagnosis:
Treatment: (Include surgery, hospitalized, durable medical equipment/supplies, etc.)
Medication Names: (Include those taken orally, injected, infused, topically, nasally, inhaled, etc.)
Dates Treated:
Is Treatment Ongoing? If yes, provide details of any current OR future treatment.
Question Number:
Enrollee Name:
Condition/Diagnosis:
Treatment: (Include surgery, hospitalized, durable medical equipment/supplies, etc.)
Medication Names: (Include those taken orally, injected, infused, topically, nasally, inhaled, etc.)
Dates Treated:
Is Treatment Ongoing? If yes, provide details of any current OR future treatment.
Question Number:
Enrollee Name:
Condition/Diagnosis:
Treatment: (Include surgery, hospitalized, durable medical equipment/supplies, etc.)
Medication Names: (Include those taken orally, injected, infused, topically, nasally, inhaled, etc.)
Dates Treated:
Is Treatment Ongoing? If yes, provide details of any current OR future treatment.
Question Number:
Enrollee Name:
Condition/Diagnosis:
Treatment: (Include surgery, hospitalized, durable medical equipment/supplies, etc.)
Medication Names: (Include those taken orally, injected, infused, topically, nasally, inhaled, etc.)
Dates Treated:
Is Treatment Ongoing? If yes, provide details of any current OR future treatment.
Question Number:
Enrollee Name:
Condition/Diagnosis:
Treatment: (Include surgery, hospitalized, durable medical equipment/supplies, etc.)
Medication Names: (Include those taken orally, injected, infused, topically, nasally, inhaled, etc.)
Dates Treated:
Is Treatment Ongoing? If yes, provide details of any current OR future treatment.
Question Number:
Enrollee Name:
Condition/Diagnosis:
Treatment: (Include surgery, hospitalized, durable medical equipment/supplies, etc.)
Medication Names: (Include those taken orally, injected, infused, topically, nasally, inhaled, etc.)
Dates Treated:
Is Treatment Ongoing? If yes, provide details of any current OR future treatment.
Question Number:
Enrollee Name:
Condition/Diagnosis:
Treatment: (Include surgery, hospitalized, durable medical equipment/supplies, etc.)
Medication Names: (Include those taken orally, injected, infused, topically, nasally, inhaled, etc.)
Dates Treated:
Is Treatment Ongoing? If yes, provide details of any current OR future treatment.
