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EnrollmentChange Request Aetna Health Vision - OnePoint HRO

EnrollmentChange Request Aetna Health Vision - OnePoint HRO 2026

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The document is an Enrollment/Change Request form for Aetna Health/Vision insurance, intended for employees to submit their enrollment or changes in coverage. It includes sections for employer and employee information, types of activities (new enrollment, changes, removals), plan options, and individuals covered. Employees must complete the form accurately to avoid processing delays and provide necessary signatures. The document also outlines conditions of enrollment and legal acknowledgments regarding the accuracy of information provided.

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Click ‘Get Form’ to open it in the editor.
Begin with Section A, where you will indicate the type of activity. Check the appropriate boxes for new enrollment or changes, and provide effective dates as required.
In Section B, fill out your personal information accurately, including your Social Security Number and contact details. This ensures your request is processed without delays.
Move to Section C to select your plan options. Choose one health plan option and check the Aetna Vision box if applicable.
Section D requires you to list individuals for whom you are adding or changing coverage. Use 'A', 'C', or 'R' to specify actions for each dependent listed.
Finally, complete Section E by signing and dating the form. This step is crucial for processing your enrollment or change request.

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