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RBG, SAN JOSE - FORMS
AETNA RELEASED DOWNLOAD
Employer Enrollment
Aetna Employer Application - 2016
6/17/2016   Download
Aetna FTE 1-100 Form
4/25/2016   Download
Attestation Form
8/23/2016   Download
Automated Clearing House New Business Request Form
2/10/2016   Download
New Small Business Checklist
8/23/2016   Download
PayFlex Application

Description:
Employer enrollment form for POP, FSA or TRA. (pdf , 572k)
Version: GR-68733

4/25/2016   Download
PayFlex Plans - Pricing Guide

Description:
Fees for POP, FSA and TRA accounts. (pdf , 102k)

4/25/2016   Download
Small Employer Proof of Eligibility Form

Description:
For Sole Proprietors, Partners, or Corporate Officers (pdf , 36k)

4/13/2016   Download
Employee Enrollment
Aetna Employee Enrollment/Change Form - 2016
6/17/2016   Download
Small Group enrollment Guide

Description:
Employee enrollment guide to Aetna services (pdf , 471k)

4/13/2016   Download
Transition of Care Form
10/14/2010   Download
Transition of Care Q&A
10/14/2010   Download
Administration
Aetna Administration Manual - California
7/21/2016   Download
Authorization for Release of Protected Health Info

Description:
Authorization form to release protected health information (pdf , 30k)

5/23/2003   Download
HIPAA Privacy Rules Q&A

Description:
HIPAA Administrative Simplification and Privacy - An Update on Aetna's Compliance Efforts (pdf , 60k)

5/23/2003   Download
HIPAA Release Form

Description:
Authorization for release of protected health information. (pdf , 478k)

4/25/2016   Download
HIPAA Release Form - Spanish

Description:
. (pdf , 484k)

4/25/2016   Download
New Regulations on HIPAA (Privacy Rules)

Description:
Document to help producers understand some of the privacy regulations recently issued by the Dept. of Health and Human Services (5/03) (pdf , 49k)

5/23/2003   Download
Notice of Occurrence - CalCOBRA

Description:
Group Size 2 - 19. Employer Notice of Occurrence of Qualifying Event for the Right to Continuation of Coverage (pdf , 604k)

4/26/2016   Download
Claims
Aetna Deductible Credit Letter

Description:
Please click here to download Aetna's deductible credit letter. (DOC , 30k)

4/15/2013   Download
Dental Claim Form

Description:
Group Size 2+ (pdf , 396k)

4/13/2016   Download
Medical Claim Form

Description:
Group Size 2+ (pdf , 707k)

4/13/2016   Download
Prescription Drug Mail Order

Description:
Prescription Drug Mail Order Claim Form (pdf , 1042k)
Version: 05-09-301

7/6/2016   Download
RX Claim Form
4/13/2016   Download
Vision Claim Form
4/13/2016   Download
Other
2016 Underwriting Guide - Effective 10/1/2016
8/23/2016   Download
4-Tier Open Aetna Value RX Listing
4/15/2016   Download
4-Tier Value Plus RX Drug Listing
4/15/2016   Download
Aetna Choice (MC) Provider Directory

Description:
Aetna Choice (MC) Provider Directory for Northern CA (4/03) (pdf , 1264k)

4/25/2003   Download
Aetna Choice (MC) Provider Directory

Description:
Aetna Choice (MC) Provider Directory for Central Valley (4/03) (pdf , 747k)

4/25/2003   Download
Aetna Choice (MC) Provider Directory

Description:
Aetna Choice (MC) Provider Directory for San Diego County (4/03) (pdf , 747k)

4/25/2003   Download
Aetna Choice (MC) Provider Directory

Description:
Aetna Choice (MC) Provider Directory for Kern & LA Counties (4/03) (pdf , 1620k)

4/25/2003   Download
Aetna Choice (MC) Provider Directory

Description:
Aetna Choice (MC) Provider Directory for Orange County (4/03) (pdf , 870k)

4/25/2003   Download
Aetna Choice (MC) Provider Directory

Description:
Aetna Choice (MC) Provider Directory for Riverside & San Bernardino Counties (4/03) (pdf , 681k)

4/25/2003   Download
Aetna Choice (MC) Provider Directory

Description:
Aetna Choice (MC) Provider Directory for SLO, Santa Barbara and Ventura Counties (4/03) (pdf , 490k)

4/25/2003   Download
Aetna DocFind
1/17/2012   Download
Aetna Personalized Cost Estimator Tool Flyer

Description:
Please click this link for details on Aetna's new Cost Estimator Tool! (pdf , 1015k)

8/13/2010   Download
Aetna Plan Guide Jan 2014

Description:
Plans and Underwriting Guidelines eff 4-1-12 (pdf , 898k)

2/7/2014   Download
Aetna Renewal Employer Change Form
8/13/2009   Download
Aetna Renewal Guide April 2013
4/15/2013   Download
Agent Agreement

Description:
Individual & Small Group (2-50 Employees) Agent Agreement (pdf , 102k)

2/10/2012   Download
Agent Agreement Amendment
2/10/2012   Download
Agent Agreement Indv. & Small Group (2-50)

Description:
Individual and Small Group Business (2-50) Agent Agreement (3/03) (pdf , 108k)

5/23/2003   Download
Agent/Agency Agreement Instruction Checklist

Description:
Individual & Small Group Business (2-50 eligible employees) - Checklist (pdf , 28k)

5/23/2003   Download
Agent/Agency Application for Appointment

Description:
Individual & Small Group Business (2-50 Employees) application for appointment (pdf , 105k)

2/10/2012   Download
Agent/Agency Application for Appointment

Description:
Individual & Small Group (2-50) Agent/Agency Application for Appointment (4/03) (pdf , 71k)

5/23/2003   Download
Agent/Agency Appointment Checklist

Description:
Individual & Small Group Business (2-50 employees) Appointment Instruction Checklist (pdf , 78k)

2/10/2012   Download
CA Commission Schedule

Description:
Small Group Business (2-50) California Commission Schedule (all products) 3/03) (pdf , 55k)

5/23/2003   Download
Handicap Child Continuation of Med Request
4/13/2016   Download
Handicapped Child Disabled Student APS
4/13/2016   Download
Plan Change Request Form

Description:
Amendment request form (plan changes on existing accounts) (doc , 46k)

6/24/2003   Download
Tips To Maximize Aetna Your Pharmacy Benefits

Description:
. (doc , 22k)

7/5/2011   Download
W-9

Description:
Request for Taxpayer Identification Number and Certification (for licensing) (1/2002) (pdf , 28k)

5/23/2003   Download