PARTICIPANT INFORMATION:
___________________________________
Print Name
_______________
Employee ID
____________
Ext.
If you elect the Aetna HMO Deductible Medical Plan, you are required to designate a Primary Care Physician
(PCP) for each covered family member to manage each person’s care and for referrals to specialists as needed.
You have the right to designate any primary care provider who participates in the Aetna HMO Deductible Plan
Network and who is available to accept you or your covered family members. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization to access obstetrical or gynecological care from a health care professional in the network who specializes obstetrics or gynecology.
However, you may be required to comply with certain procedures when obtaining prior authorizations or preapprovals for referrals or treatment. If you do not designate a PCP, Aetna will assign a PCP for you. You may change your PCP the first of any month, provided you notify Aetna of the change before the 16 th
of the preceding month.
To find a PCP in the Aetna HMO Deductible Plan Network, visit www.aetna.com
. Select Find a Doctor; under
Plan, select Aetna HMO Deductible under Aetna Standard Plans. Each family member may choose a different
PCP and/or medical group.
Please list a Primary Care Physician for yourself and any enrolled family members. You must also indicate if you are a current patient.
□ Check here if you would prefer that Aetna auto-assign a PCP for you and your family.
Last Name, First Name Date of Birth Primary Office ID# Name of Provider Current
Patient
____________ __________________ __________________________ Yes / No ___________________________
Employee
___________________________
Spouse
____________ __________________ __________________________ Yes / No
___________________________
Child
___________________________
Child
____________ __________________ __________________________ Yes / No
____________ __________________ __________________________ Yes / No
___________________________ ____________ __________________ __________________________ Yes / No
Child
I understand that coverage is being provided by the following companies: Aetna Life Insurance Company HMO, QPOS®:
Aetna Health Inc., Aetna Health of California Inc. The plan documents (Schedule of Benefits, Group Agreement, Group
Policy, and Certificate of Coverage) will determine my rights and responsibilities and will govern even if they conflict with any benefits comparisons, summary or other description of the plan. I understand and agree that with the exception of Aetna
Rx Home Delivery®, all participating providers and vendors are independent contractors and are neither agents nor employees of Aetna. The availability of any particular product cannot be guaranteed and provider network composition is subject to change.
NOTICE: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or who 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.