D. Individuals covered (Continued)
Sex (M/F) Social Security number
Name (Last, first, middle initial)
Child
Stepchild
Add
Other
4
Change
Remove
Birthdate (MM/DD/YYYY)
Handicapped
Choosing coverage for:
Yes No
Dental
Vision
/
/
Dental provider office ID number
Current patient
Yes
Sex (M/F) Social Security number
Name (Last, first, middle initial)
Child
Stepchild
Add
Other
5
Change
Remove
Birthdate (MM/DD/YYYY)
Handicapped
Choosing coverage for:
Yes No
Dental
Vision
/
/
Dental provider office ID number
Current patient
Yes
Sex (M/F) Social Security number
Name (Last, first, middle initial)
Child
Stepchild
Add
Other
6
Change
Remove
Handicapped
Choosing coverage for:
Birthdate (MM/DD/YYYY)
Yes No
Dental
Vision
/
/
Dental provider office ID number
Current patient
Yes
E. Dependent information
List any dependent in Section D with a different last name or living at another address.
Name
Address
F. Coordination of benefits
Will you have other insurance at the same time as this coverage? Yes No
If yes , will the Aetna coverage you’re applying for replace the coverage you have now?
Yes No
Name of person
Carrier name
Name of person
Carrier name
Disclosure acknowledgment
I understand that I am enrolling in a health care plan issued by Aetna Health Inc. or Aetna Life Insurance Company (“Aetna”) that requires health care
services be provided by participating providers. Failure to use a participating provider will result in reduced coverage or no coverage for services that I
receive, and I will be fully responsible for any and all costs not covered by Aetna.
I received a list of participating providers. I may verify the participation status of a provider by using the provider search at Aetna’s web site,
http://www.Aetna.com . The provider search site is updated weekly and can also be used to select a provider based on name, geographic location,
group practice, medical specialty and / or hospital affiliation. I may also verify provider status by contacting Member Services at the number listed on
my member ID card. I understand that the participation status of any provider may change from time to time and that it is my responsibility to verify
participation of my health care provider with Aetna prior to receiving services.
As required by the state of Georgia regulations, the following is a summary of the financial arrangements with health care providers who are
participating in the Aetna Health Inc. network:
1. Hospital providers are paid according to a contract that includes inpatient per diems, case rates, and discounted fee for service arrangements
depending on the specific services provided.
2. Physicians are paid either a discounted fee for service in accordance with a specific fee schedule or a predetermined set amount per member per
month (capitation).
3. Laboratory services are provided through a capitation arrangement (a per member per month flat fee).
4. Other ancillary services including home health, skilled nursing, and hospice are paid on a contracted fee schedule with per diems or per visit
amounts, or through a capitated per member per month flat fee.
7000-2-SG
7000-2 (6-18)
3
SG (1-50) GA V2 B
13 Slappey & Sadd, LLC 2025 Benefits Guide |
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