PARTICIPANT INFORMATION:
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Print Name
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Employee ID
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Ext.
If you elect the Aetna Value Network 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. 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 Value HMO Network, visit www.aetna.com
. Select Find a Doctor; under Plan, select
Aetna Value Network 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.
□ 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
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Employee
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Spouse
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Child
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Child
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Child
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Child
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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.
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Signature Date
Y OU MUST RETURN THIS FORM TO HR A LONG WITH YOUR B ENEFIT E NROLLMENT F ORM