Healthcare Aetna Application

HEALTHCARE AETNA APPLICATION

This application requests enrollment, coverage selection and authorizations necessary to process health plan membership through Aetna. Completion of this form does not guarantee acceptance; eligibility and effective dates are subject to underwriting, plan rules and payment of required premiums. In signing, Applicant certifies the information provided is true, complete, and accurate to the best of Applicant's knowledge and authorizes verification of any information provided herein.

Application Type

Enrollment Category: Individual Family Employer-Sponsored Medicare Advantage

Enrollment Reason: New Enrollment Open Enrollment Special Enrollment (qualifying event) Change of Plan

Applicant Information

Applicant Name:

Date of Birth:    Gender: Male Female Other

Insurance & Coverage Details

Subscriber Name:    Coverage Effective Date:

Desired Plan Name/Type:    Requested Effective Date:

Dependent Information

Dependent 1:

DOB:    Gender: M F Other    Relationship:

Dependent 2:

DOB:    Gender: M F Other    Relationship:

Medical History & Health Information

Do you use tobacco or nicotine products? Yes No    Are you pregnant? Yes No If pregnant, expected delivery date:

Authorization, Privacy & Certification

By signing below, Applicant authorizes Aetna and its agents to obtain and disclose medical information, claims history, prescription records and other information necessary to determine eligibility, premiums, coverage and to administer benefits. This authorization includes information about diagnosis, treatment, hospital records and payment history. Applicant further authorizes release of information to providers, reinsurers and other entities for claims processing and care coordination.

Applicant acknowledges receipt of the Notice of Privacy Practices and consents to the use of electronic communications where permitted. Applicant understands that material misrepresentation or omission of fact may be grounds for rescission, retroactive termination of coverage or denial of claims in accordance with plan terms and applicable law.

Assignment of Benefits: Applicant assigns benefits payable for covered services to the provider when so directed. Applicant certifies that Applicant is financially responsible for all required premiums and for any services not covered by the plan.

Authorization Expiration: This authorization remains in effect for as long as necessary to process this application and for plan administration, unless revoked in writing by Applicant, subject to the rights of any third parties who relied on the authorization prior to revocation.

Fraud Warning: Intentional falsification of information may be a crime and may subject Applicant to civil and criminal penalties. Applicant will notify Aetna of any change in eligibility, address, or other material facts within thirty (30) days of change.

Applicant Certification: I certify under penalty of perjury that the information provided on this application is true and correct. I understand that approval of coverage is contingent upon eligibility verification, underwriting and receipt of premiums when applicable.

I acknowledge and agree to the statements, authorizations and certifications above.

Additional Information

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