This page gives you immediate access to the plan description and forms
you will need to help employers and their staff get the information
that is easy to understand and use.
Aetna - Forms & Applications
< Go Back    or view forms & apps for:
Aetna  |  American Fidelity  |  Blue Cross  |  Blue Shield  |  First Dental Health  |  Health Net  |  Kaiser  |  PacifiCare  |  Sharp  |  Sterling HSA  |  The Standard  |  UHC  |  Unum
 
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Select a SubCategory...    Group Medical   |   Dental   |   Life & Disability   |   Vision
Company
Group Medical - EMPLOYEE
 Description Form # Rev Date Fillable
Aetna
Employee Enrollment

 Use this form to enroll employee and their family. California Small Group Business (2-50 eligible employees)
GR-67834
11-08
  
Aetna Use this Spanish form to enroll employee and their family. California Small Group Business (2-50 eligible employees)
GR-67834-3-SP
4-07
  
Aetna For existing enrollments only
GR-68313
11-08
  
Aetna HSA Employee Enrollment Form     10-08  
Company
Group Medical - EMPLOYER
Description Form # Rev Date Fillable
Aetna

Employer Application

 California Small Group Business Employer Application for group coverage (2-50 eligible employees)
AGR-96241
11-08
  
Aetna Aetna HealthFund® Health Savings Account (HSA) Enrollment (Small Group)
10-08
  
Aetna Small Group Business Employer HSA Contribution Form and Instruction Sheet
GR-68112
10-06
 Yes
Aetna Medicare Advantage Application for Small Group Employers
GR-68448-2
11-06
  
Company
Group Medical - OTHER
Description Form # Rev Date Fillable
Aetna Mental Health Provider's Statement
GC-1422-4
06-02
 Yes
Aetna California Group Health Coverage Employer Notice of Occurrence of Qualifying Event for Right to Continuation Coverage under CalCobra Consumer Markets 2-19 size groups
GR-67564
05-04
 Yes
Aetna Aetna HealthFund® Health Savings Account (HSA) Beneficiary Designation
GS-1546-1
10-05
  
Aetna Commercial Prescription Drug Claim Form
GC-1360
02-07
 Yes
Aetna Attending Physician Behavioral Health Statement
GC-1493-2
06-03
 Yes
Aetna Employee Request For Information
GC-1502-2
08-03
 Yes
Aetna Reimbursement Request. Fillable Form.
GC-1578
12-06
 Yes
Aetna Cancellation Opt-Out FSA Form. If you are a member of an Aetna medical, dental or pharmacy plan, Streamline is a way for you to have your Health Care Flexible Spending Account claims paid without filling out a claim form. Your employer has automatically enrolled you in the Streamline option if you have signed up for a Health Care Flexible Spending Account.
GC-1579
01-07
  
Aetna HRA Reimbursement Request
GC-1593
11-07
 Yes
Aetna Cancellation Opt-Out HRA Form. If you are a member of an Aetna medical, dental or pharmacy plan, Streamline is a way for you to have your Health Care Flexible Spending Account claims paid without filling out a claim form. Your employer has automatically enrolled you in the Streamline option if you have signed up for a Health Care Flexible Spending Account.
GC-1594
11-07
  
Aetna Medical Benefits - Claim Instructions and form.
GC-7-39
02-04
  
Aetna California Group Health Coverage. Employer Notice of Occurrence of Qualifying Event for the Right to Continuation Coverage under CalCOBRA Consumer Markets 2-19 size groups.
GR-67564
05-04
 Yes
Aetna Coverage for a Special Dependent Child.
GR-67814
11-03
 Yes
Aetna Authorization For Release Of Protected Health Information.
GR-67938
03-03
  
Aetna Spanish Version
GR-67938-SP
03-03
  
Aetna Agreement to the establishment of an insurance trust fund for the purposes of implementing a Trust Agreement, and to designation of the Chase Manhattan Bank Delaware, DE, as "Trustee" for the Fund and Agreement Form.
GR-67987
07-03
 Yes
Aetna Small Group Business COBRA/CAL.COBRA Questionnaire (For use in CA only). This form must be completed when replacing another group plan.
GR-68924
04-04
  
Aetna Declaration Of Domestic Partnership
N/A
3-08
  
Aetna Declaration Of Termination of Domestic Partnership
N/A
3-08
  
Aetna Proof of Eligibility Form For Small Employer (2-50) Sole Proprietors, Partners or Corporate Officers (To be used for eligible individuals that are not reported on a quarterly wage and tax form).
N/A
06-04
 Yes
Aetna  
GC-1395
03-06
 Yes
Select a SubCategory...    Group Medical   |   Dental   |   Life & Disability   |   Vision
Company
Dental
 Description Form # Rev Date Fillable
Aetna Dental Benefits - Claim Instructions and Form
GC-8-13
01-04
 Yes
Aetna Spanish Version
GC-8-5-SP
01-04
 Yes
Aetna For Employers. California Small Group Business. This application is to be used by existing Aetna Small Groups within 60 days of the original Aetna Medical effective date.
GR-68107-2
11-06
 Yes
Aetna For Employees. California Small Group Business. This application is to be used by existing Aetna Small Groups within 60 days of the original Aetna Medical effective date.
GR-68108-2
11-06
 Yes
Company
Life Insurance
Description Form # Rev Date Fillable
Aetna Proof of Death - Group Life Insurance and Group Accidental Death Benefit Request.
GC-1373
03-04
 Yes
Aetna Spanish Version
GC-1373-SP
03-04
  
Company
Vision
 Description Form # Rev Date Fillable
Aetna N/A        
< Go Back    or view forms & apps for:
Aetna  |  American Fidelity  |  Blue Cross  |  Blue Shield  |  First Dental Health  |  Health Net  |  Kaiser  |  PacifiCare  |  Sharp  |  Sterling HSA  |  The Standard  |  UHC  |  Unum