Get Aetna Disenrollment Form

Filling out the Aetna Disenrollment Form online is a straightforward process that allows users to ensure their application is completed accurately and efficiently. This guide provides step-by-step instructions to help you understand each section of the form.

Follow the steps to complete the Aetna Disenrollment Form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering the effective date. This date will be the first day of the month following the date you sign the form or according to the effective date of your group health plan.
3. In the former employer section, provide the name of your previous employer or union that offers this health plan. If applicable, list the group number, though this is not mandatory.
4. Complete the personal information section with your name, address, phone number, and other requested details. Ensure that your print is clear for accurate processing.
5. In the Medicare information section, carefully provide your Medicare insurance information using your Medicare card to avoid delays in processing.
6. Select your desired health plan by checking the appropriate box for the Aetna Medicare Advantage plan you wish to enroll in.
7. If you are enrolling in an HMO plan, specify your selected Aetna Medicare primary care physician (PCP) name and office ID. For PPO plans, choosing a PCP is recommended.
8. For HMO plans offering dental benefits, include the name and office ID of your chosen primary dentist.
9. Answer the Medicare-related questions to assist Aetna in coordinating your benefits and providing accurate coverage.
10. Sign and date the form in the designated area. If you are completing this form as a representative, ensure to include your information.
11. Make a copy of the completed application for your records, then mail the original form to the specified address.

Start completing your Aetna Disenrollment Form online today.