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RBG, CHICAGO - FORMS
AETNA RELEASED DOWNLOAD
Employer Enrollment
2-100 Employer Application
2/27/2016   Download
2-50 New Business Checklist
2/27/2016   Download
51-100 New Business Checklist
2/27/2016   Download
ACH Form
2/27/2016   Download
Common Ownership Form
2/27/2016   Download
Company Name or Tax ID # Changes
2/27/2016   Download
Gatekeeper Census 51-100

Description:
Renewals <30% GMQ’s are no longer required; IMQ is also accepted. Renewals <30% : IMQ’s are mandatory. (xls , 27k)

3/27/2014   Download
Employee Enrollment
2 - 50 Employee Application & Change Form
2/27/2016   Download
2 - 50 Employee Application & Change Form - Spanis
2/27/2016   Download
2-100 New Business List Enrollment

Description:
Fully Insured Only (xls , 2498k)

2/27/2016   Download
51-100 Employee Application & Change Form
2/27/2016   Download
Administration
Business Name Change Form
2/27/2016   Download
HIPAA Authorization Form - English
2/27/2016   Download
HIPAA Authorization Form - Spanish
2/27/2016   Download
IL Small Group Enrollment Guide 6.15
2/27/2016   Download
Small Group Administration Manual
2/27/2016   Download
Small Group New Customer Quick Start Guide 10.15
2/27/2016   Download
Claims
Continuation of Coverage for Handicapped Dependent
2/27/2016   Download
Dental Claim Form
2/27/2016   Download
Disability Attending Physician's Statement
2/27/2016   Download
FSA Claim Form
2/27/2016   Download
Handicapped Dependent Attending Physician's Statem
2/27/2016   Download
Medical Claim Form
2/27/2016   Download
Rx Claim Form
2/27/2016   Download
STD & LTD Claim Form
2/27/2016   Download
Term Life Claim Form
2/27/2016   Download
Vision Claim Form
2/27/2016   Download
Other
Mail Order Form
2/27/2016   Download