Aetna Open Enrollment Form

I have read and agree to the conditions of enrollment on the reverse side of this enrollment change request form.

Aetna open enrollment form.

If your re retiring moving out of state or changing provider groups use this form to notify us. Just log in to your benefits enrollment site to find all aetna plans and programs available to you. Enroll in the aetna plan right for you. Please complete this form if you re interested in joining aetna s network and you are a medical health care professional physician or non physician.

Open enrollment has ended if you missed open enrollment please contact your hr representative immediately. Your new coverage starts on january 1 2020. You ll automatically be disenrolled from your old plan when your new coverage begins. Set aside time to review your options and compare them side by side.

Fill out this form if you were billed directly by a provider and would like to request reimbursement for medical care includes dental vision hearing and vaccines. I certify that all information supplied in this form is true and complete to the best of my knowledge and or belief. It s a new enrollment type in the fehb program. Together banner and aetna are taking a new approach to the way health care is offered.

We ll need to terminate your existing agreement with us. Applicable only durin g open enrollment or upon employment termination. Gr 68000 6 8 10 enrollment change request aetna life insurance company employer group information. This form will also update your information on the online provider directory.

Starting in 2016 all fehb plans including aetna will offer self only self plus one and self and family enrollment options. I am a new member please indicate your medical and dental enrollment option if a rehire please enter your prior aetna wid terminate coverage. Employees and annuitants will be able to select this beginning in the 2015 open season. To avoid potential errors please do not submit a form if no changes are being made.

You ll be able to cover yourself and one eligible family member. If your re moving or changing jobs you can sign a new agreement for your new practice or location. Print a prescription drug claim form print a prescription drug claim form spanish print and complete this form for medical dental vision hearing or vaccine reimbursement. The path to healthy starts here.