Aetna HMO Primary Care Physician Designation Form
PARTICIPANT INFORMATION:
___________________________________
Print Name
_______________
Employee ID
____________
Ext.
If you elect the Aetna HMO 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 HMO 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.
To find a PCP in the Aetna HMO Network, visit www.aetna.com. Select Find a Doctor; under Plan, select HMO
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
YOU MUST RETURN THIS FORM TO HR ALONG WITH YOUR BENEFIT ENROLLMENT FORM