see all offices

RBG, TAMPA-FT. MYERS - FORMS
AETNA RELEASED DOWNLOAD
Employer Enrollment
Employer Addendum Attestation Form

Description:
Required for all new groups under 200 lives, effective 10/1/11. (pdf , 248k)
Version: GR 68720 (7-11)

7/29/2011   Download
Employer Application

Description:
New small group app with current plans, non-medical and out-of-state coverages; including HSA and HCR revisions (10-10) (pdf , 909k)
Version: GR-96241-FL

2/8/2011   Download
HCR Employer/Employee form

Description:
Used to notify employers and employees of certain changrs required by Health Care Reform (pdf , 103k)

8/13/2010   Download
Proof of Eligibility Form

Description:
For Sole Proprietors, Partners or Corporate Officers - to be used for eligible individuals that are not reported on a quarterly wage and tax form (pdf , 41k)
Version: 5/19/2006

6/28/2011   Download
Small Group Business Group Medical Questionnaire

Description:
For use with groups with 10-50 ELIGIBLE employees. May be used for pre-screening. (pdf , 91k)
Version: 6/03

6/28/2011   Download
Employee Enrollment
Enrollment/Change form (SGR)

Description:
For 2 - 50 (10-10) (pdf , 687k)
Version: GR-67834-1

2/8/2011   Download
Enrollment/Change form (SGR) - Spanish

Description:
For 2 - 50 (12-07) (pdf , 371k)
Version: GR-67834-1 SP

2/8/2011   Download
HCR Employer/Employee form

Description:
Used to notify employers and employees of certain changrs required by Health Care Reform (pdf , 103k)

8/13/2010   Download
Administration
Doc Find

Description:
Instructions for using Aetna Doc Find (pdf , 8414k)
Version: 5/03

6/28/2011   Download
Claims
Mail Order Rx Claim Form

Description:
Aetna Home Delivery Rx Claim Form (pdf , 246k)
Version: 6/06

6/28/2011   Download
Medical Claim Form - HMO
12/2/2010   Download
Medical Claim Form - PPO
12/2/2010   Download
Rx Claim Form

Description:
Submit a prescription claim for reimbursement. (pdf , 347k)

11/11/2010   Download
Other
Employer Verification Form

Description:
Must be completed prior to renewal review (pdf , 84k)
Version: EI930 (6-10)

4/8/2011   Download
Generic Excel Census Form

Description:
May be used for any carrier. Non-medical coverages may require additional fields. (XLS , 68k)

12/2/2010   Download
Generic Excel Census Form including Non-Meds

Description:
May be used for any carrier. Duplicate or extend as necessary. (XLS , 69k)

12/2/2010   Download