Forms and Documents

Small Business Enrollment Forms

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Your state: California

Administrative Tools

Enrollment Guide (24 pages)
Enrollment Guide - Spanish (24 pages)
Enrollment form tool
Administration Manuals
Renewal Instructions - October 2010 renewal (36 pages)
Renewal Instructions - September 2010 renewal (28 pages)
Renewal Instructions - for effective dates 5/1/10 through 4/15/2011 (28 pages)
Renewal Instructions - for effective dates 1/1/2010 thru 4/15/2010 (27 pages)
Contact Sheet (2 pages)

American Recovery and Reinvestment Act of 2009 (ARRA)

Employer Attestation ARRA state continuation employee subsidy (1 page)

Enrollment Forms

Employer - Dental Verification Form (1 page)
Employee Enrollment/Change Form (6 pages)
Employee Enrollment/Change Form - Spanish (6 pages)
Employee Change of Coverage Application - for existing enrollments only (3 pages)
Employee Change of Coverage Application - Spanish - for existing enrollments only (4 pages)
Employee - Dental Life Group Election Form (3 pages)
Employee - Dental Life Group Election Form - Spanish (3 pages)
Employer - Dental Life Group Election Form (1 page)
Employer - Application (6 pages)
Employee - 2010 Medicare Group Enrollment Form (HMO) (4 pages)
Employee - 2010 Medicare Group Enrollment Form (PFFS) (4 pages)

Aetna HealthFund HSA with HealthEquity
For new HSA-compatible business that started with 10/1/08 effective dates.

Visit http://aetna.healthequity.com for enrollment forms.

Aetna HealthFund HSA Forms - For business prior to 10/1/08

HSA Small Group Member Enrollment Form (1 pages)
HSA Beneficiary Form (2 pages)
HSA AutoDebit Information (4 pages)
HSA EFT form (1 pages)
Employer HSA Contribution Form - PDF version (3 pages)
Employer HSA Contribution Form - Excel version
HSA Rollover Form (1 page)
HSA Deposit Slips (1 page)

Vitalidad México con AetnaTM

Vitalidad México con Aetna Employee Brochure (4 pages)
Vitalidad México con Aetna Employee Brochure (Spanish) (4 pages)

Claims/Reimbursement Forms

Medical Claim Form (2 pages)
Dental Claim Form (2 pages)
Pharmacy Claim Form (2 pages)
Vision Claim Form (2 pages)
Term Life Claim Form (2 pages)
Disability Claim Form (1 page)
Disability Attending Physician Statement (2 pages)
Mail Order Delivery Registration/Order Form (2 pages)
Handicapped Child Continuation of Medical Coverage (2 pages)
Handicapped Child Attending Physical Statement (2 pages)

Tools for Employers & Organizations

Legal Notices

Health benefits and health insurance plans contain exclusions and limitations. See plan documents for a complete description of coverage.

Transforming Health Care

Better quality, lower costs

We are taking on rising health care costs and quality challenges by advocating health delivery payment reform that rewards quality, not volume.

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