Fillable Form Nj Hint - Aetna Enrollment/change Nj 101 Or More Employees (Page 4 of 4) in pdf

NOTE: To Add, Change, or Remove coverage for dependents over the limiting age, but less than 31, Aetna form HINT

Supplemental Enrollment Information Form, Implementing P.L.2005,c.375, must be completed.

Instructions

Employer

● Complete Section K - Employer Verification.

● Employer must complete this section for all new enrollments, coverage changes and terminations.

● Employer must sign and date this Enrollment/Change Request form in order for it to be processed.

Employee – Complete Sections A – J

Section A – Type of Activity:

● Check boxes indicating reason(s) for submitting application.

● Employee must complete this section for all new enrollments, coverage changes and terminations.

● Employer must sign and date Section L of this Enrollment/Change Request form in order for it to be processed.

Section B – Medical Plan Options:

● Check one plan option box and indicate Plan Option Name (where applicable).

● Select only an option offered by your employer.

Section C – Employee Information:

Complete all information in order for your application to be processed.

Section D – Individuals Covered:

● Do not complete this form for dependents over the limiting age, but less than 31; Aetna Form, HINT Supplemental Enrollment Information Form Implementing

P.L. 2005, c. 375, must be completed.

● Add/Change/Remove - Use "A", "C", or "R" to indicate whether you are adding, changing or removing coverage for an individual.

● Print your full name along with the name(s) of your dependents, if applicable. Indicate Sex, Social Security Number and Birthdate for each individual listed.

● If dependent is disabled and being continued beyond the limiting age, attach proof of disability.

● If you or your dependent(s) have other Health or Rx drug coverage, check off the Yes box(es) and complete Section I - Other/Previous Insurance.

● From the appropriate provider directory, locate the 6-digit office ID number for the primary care physician and/or dentist (if applicable). Indicate office ID number

selection(s) on the form.

● You may obtain each provider's NPI number by contacting the provider directly. Providers with multiple office locations and individual providers who belong to

more than one practice or provider entity may have more than one NPI number. You should confirm the correct NPI number for the specific provider and office

location where you will be seen by contacting the office directly.

● If you are a current patient, please check the "Current Patient" box.

● If you had previous coverage, please check the “Previous Coverage” box.

Section E – Race/Ethnicity (Optional):

Check the appropriate Race/Ethnicity code for each individual. If your Race/Ethnicity is “Other,” print the Race/

Ethnicity for each individual in the space provided.

Section F – Declination/Waiver of Coverage:

Complete this section if declining coverage for any eligible employee and/or their eligible family members.

Employee must sign and date.

Section G – Dependent Information:

Complete this section for all new enrollments or coverage changes.

Section H – Other Insurance:

Complete this section for all new enrollments or coverage changes. Coverage includes group coverage, governmental coverage,

a church plan or Medicare.

Section I – Conditions of Enrollment:

Please read carefully.

Section J – Employee Signature:

● Complete this section for all new enrollments, coverage changes and terminations.

● Employee must sign and date the Enrollment/Change Request form in order for it to be processed.

Section K – Employer Verification:

● Employer must complete this section for all new enrollments, coverage changes and terminations.

● Employer must sign and date the Enrollment/Change Request form in order for it to be processed.

GR-67820-2 (2-14) NJ Traditional G

NJ HINT - Group

Form Nj Hint - Aetna Enrollment/change Nj 101 Or More Employees Page 4

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