RsGR67466-2 doc 2026

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The document is an application form for Aetna Health Inc.'s New York Individual Advantage health insurance plan. It outlines the process for enrollment, including effective dates based on payment timing, subscriber and dependent information requirements, and conditions regarding preexisting conditions. The form also includes sections for changing coverage, adding or removing dependents, and necessary acknowledgments from the subscriber regarding eligibility and coverage terms.

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Click ‘Get Form’ to open the rsGR67466-2 document in the editor.
Begin with Section 1 by selecting your plan option (HMO or QPOS) and ensure you read the instructions on the reverse side for clarity.
In Section 2, fill in your Subscriber Information, including your last name, first name, middle initial, and Social Security Number. Provide your home address and telephone numbers.
Proceed to Section 3 to indicate the type of activity—whether you are a new subscriber or converting coverage from a prior Aetna group plan.
Complete Section 4 by listing dependents. Include their names, birthdates, and Social Security Numbers. If applicable, attach proof for full-time college students.
In Section 9, ensure you sign and date the form. This is crucial for processing your application.

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