Conditions of enrollment
I understand that the following legal entities underwrite the plans I apply for:
Aetna Health Inc. underwrites the Aetna dental DMO ®
plans.
Aetna Life Insurance Company underwrites the Aetna dental plans (except DMO ®
) and Aetna vision plans.
1. My employer’s application determines coverage. I don’t have coverage until Aetna approves my employee enrollment form and the employer
application. Even if Aetna approves the employer application, any misstatements or omissions may result in denial of future claims. Aetna may
rescind or reevaluate my coverage under the policy, as of the effective date, for eligibility and rating purposes. If Aetna voids or rescinds
coverage, I may be entitled to a refund of any paid premiums from the effective date of coverage. Aetna will give at least 30 days advance written
notice to any covered person affected by the proposed rescission. If I elect to receive electronic notifications, I will receive this notice in an
electronic (email) format.
2. To support the coverages listed on this enrollment form, Aetna may need information about medical history, services or treatment provided to
anyone listed on this form. This may include information about mental health, substance use disorder and HIV / AIDS. I authorize that the
following entities can provide this information to Aetna or its agents:
Physicians
Other healthcare professionals
Hospitals
Other healthcare organizations (“providers”), including
Pharmacies
–
Pharmacy database benefit managers
–
3. I authorize Aetna to use and disclose such information to:
Affiliates
Providers
Other insurers
Third party administration
Vendors
Consultants
Governmental authorities with jurisdiction when necessary for:
Care or treatment
–
Payment for services
–
Operation of my health plan
–
Conduct related activities
–
4. I discussed the terms of this authorization with my competent adult dependents. They agreed to these terms. This authorization is valid for 30
months from the signature date. This authorization is valid for the term of the coverage for medical information collected in connection with a
medical claim. This authorization is voluntary. But if I don’t sign this form, my ability to enroll in the plan may be affected. I have the right to
revoke this authorization in writing to Aetna at any time. I can’t revoke authorization for information already used or disclosed before I revoked my
authorization. I am entitled to receive a copy of this authorization upon request. A photocopy is as valid as the original.
The Group Agreement / Group Policy determines the rights and responsibilities of members and will govern in the event they conflict with any:
Benefits comparison
–
Summary
–
Other description of the plan
–
Participating physicians, hospitals and other health care providers are independent contractors. They are not Aetna agents or employees.
We cannot guarantee the availability of any particular provider. Any provider network is subject to change. We will provide a notice of the
change in accordance with applicable state law.
5. I understand that, with certain exceptions described in the plan documents, HMO and DMO ©
plans only provide coverage for network covered
benefits. The plan documents also describe if I need a referral for certain procedures, and who can provide care. Covered services must be
performed by:
Participating primary care physicians
Participating primary care dentists
Participating specialists
Participating hospitals
Participating pharmacies
Participating dentists
Other participating providers as authorized by a referral from a participating primary care physician
6. I authorize the substitution of generic pharmaceuticals for the brand-name products, as provided by law, for prescriptions filled under any
pharmacy benefit.
Continued on next page
7000-2-SG
7000-2 (6-18)
4
SG (1-50) GA V2 B
14 | Slappey & Sadd, LLC 2025 Benefits Guide
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