Please select your client's company size:

Small Group (2 - 50 Eligible Employees) Middle Market (51 - 3000 Eligible Employees) National Accounts (3000+ Eligible Employees)

Small Group
2 - 50 eligible employees

Your state: Pennsylvania

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Administrative Tools

• Administration Manuals
• Enrollment form tool

Enrollment Forms

• Employer - Dental Verification Form  (1 page)
• Employee Enrollment/Change Form  (4 pages)
• Employee Enrollment/Change Form (Spanish)  (4 pages)
• 2009 Medicare Employer Application  (2 pages)
• Employer - Application and Joinder Agreement  (4 pages)
• 2009 Medicare Employer Application   (2 pages)
• 2009 Medicare Group Enrollment -Medicare Golden Advantage and Golden Choice Plans  (2 pages)
• 2009 Medicare Group Enrollment Form - PFFS "Open" Plans  (2 pages)
• Group Medical Questionnaire  (1 page)
• DE Supplemental Enrollment Form (DE HB 446)  (1 page)

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
• HSA Beneficiary Form
• HSA AutoDebit Information   (4 pages)
• HSA EFT form
• Employer HSA Contribution Form - PDF version
• Employer HSA Contribution Form - Excel version
• HSA Rollover Form
• HSA Deposit Slips
• Member Letter  (2 pages)

Aetna HealthFund HRA Materials

• HRA Plan Sponsor Brochure  (8 pages)
• HRA Employee Brochure  (4 pages)
• HRA Employee Brochure (Spanish)  (4 pages)
• Pricing Guide  (1 page)

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 pages)
• 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)