Aetna Select EPO Primary Care Physician Designation Form
PARTICIPANT INFORMATION:
___________________________________
Print Name
_______________
Employee ID
____________
Ext.
If you elect the Aetna Select EPO 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 may
change your PCP as often as you like. You have the right to designate any primary care provider who participates
in the Aetna Select EPO 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 pre-approvals for referrals or treatment.
To find a PCP in the Aetna Select EPO Network, visit www.aetna.com. Select Find a Doctor; under Plan, select
Aetna Select 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.
Last Name, First Name
Date of Birth
Primary Office ID#
Name of Provider
Current
Patient
___________________________
Employee
____________
__________________
__________________________
Yes / No
___________________________
Spouse
____________
__________________
__________________________
Yes / No
___________________________
Child
____________
__________________
__________________________
Yes / No
___________________________
Child
____________
__________________
__________________________
Yes / No
___________________________
Child
____________
__________________
__________________________
Yes / No
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.
_______________________________________
_______________________
Signature
Date