Forms and Documents

Small Business Enrollment Forms

Your state: Pennsylvania

Administrative Tools

American Recovery and Reinvestment Act of 2009 (ARRA)

Employer Attestation ARRA state continuation employee subsidy (1 page)

Health Care Reform:

Addendum to New Business Input Documents (PDF, 241 KB) Mandatory Requirement for Health Care Reform - Rebate - The employer must complete the attached to determine any potential rebates entitled under the new medical loss ratio requirements set forth in the Affordable Care Act (ACA).

Enrollment Forms

Employer - Dental Verification Form (1 page)
Employee Enrollment/Change Form (PDF, 618 KB)
Employee Enrollment/Change Form (Spanish) (PDF, 163 KB)
Employee - Individual Health Questionnaire (1 page)
Group Medical Questionnaire (PDF, 578 KB)
PA Supplemental Enrollment Form (1 page)
2009 Medicare Employer Application (2 pages)
Employer - Application and Joinder Agreement (PDF, 628 KB)
Employee - 2011 Medicare Group Enrollment for (HMO/PPO) (PDF, 307 KB)
Supplemental Dependent Enrollment/Change Form (PDF, 591 KB)
Employer Verification Form (PDF, 66 KB)

Aetna HealthFund HSA with HealthEquity
For new HSA-Compatible business only starting with 7/1/08 effective dates.

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

Aetna HealthFund HSA Forms - For business prior to 7/1/08

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

Aetna HealthFund HRA Materials

Aetna HealthFund HRA Enrollment Materials and Ongoing Administration

Cafeteria Plans Enrollment Forms

Employer Request for Participation (1 page)

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 (PDF, 260 KB)
Handicapped Child Continuation of Medical Coverage (2 pages)
Handicapped Child Attending Physical Statement (2 pages)

Tools for Small Businesses

Legal Notices

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

Health Care Reform

Health Care Reform

Get answers about health reform and learn how changes may affect businesses.

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