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  • Aetna Family Health Statement Form

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R Street Address (P.O. Box not acceptable) City State Zip Applicant s Occupation Hours Worked/Week Full Time Hire Date (MM/DD/YYYY) B. Decline Coverage Must be completed by the employee. I Decline to enroll for Health coverage due to the existence of other group health coverage for: Myself Spouse Dependent Child(ren) If I and/or my dependents decline coverage and desire to participate in the plan at a later date, I may have to submit evidence of insurability satisfactory to the i.

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Use our electronic payer ID# 60054.

Your ID number is the first 9 digits of your USC ID. For example, if your USC ID was 1234567890, your Aetna ID would be 123456789. Please use your Aetna ID when contacting Aetna regarding claim issues or general questions. Please give Aetna your Aetna ID instead of your Social Security Number.

All Aetna Medicare Advantage plan members will have 12-digit member ID numbers beginning with “10.” We will no longer use the “ME” prefix for Medicare Advantage plans after that date. Consol Energy will transition from ID numbers beginning with “ME” to those beginning with “10” on April 1, 2022.

The policy number on your insurance card is a unique code associated with your insurance plan. Your insurance company uses your policy number to track and process insurance claims and costs. Policy numbers may also be referred to as subscriber IDs or member ID numbers.

Other ways to file claims You can also print and mail claims forms to Aetna Voluntary Plans, PO Box 14079, Lexington, KY 40512-4079, or Fax to 1-859-455-8650.

FSA Identification Number - As a participant with the FSA, you have been assigned a unique participant number. Your FSA ID Number is a 9 digit number preceded with a "W".

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232