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CA Small Group Change of Coverage Form - Spanish - Aetna CA Small Group Change of Coverage Form - Sp

CA Small Group Change of Coverage Form - Spanish - Aetna CA Small Group Change of Coverage Form - Sp 2025

CA Small Group Change of Coverage Form - Spanish - Aetna CA Small Group Change of Coverage Form - Sp Preview on Page 1

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El documento es una solicitud de cambio de cobertura para empleados de pequeñas empresas en California, proporcionada por Aetna. Detalla las entidades responsables de la cobertura, instrucciones para completar la solicitud, y requisitos específicos sobre la información del empleado y sus dependientes. También incluye advertencias sobre la veracidad de la información proporcionada y menciona el arbitraje obligatorio para disputas relacionadas con el plan de salud.

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Click ‘Get Form’ to open it in the editor.
Begin by selecting your desired coverage option in the 'Elección de cobertura' section. Mark the appropriate boxes for medical and dental plans.
In the 'Información del empleado' section, provide your personal details including name, address, and contact information. Ensure all fields are filled accurately.
List any dependents you wish to enroll or change under 'Información del empleado y su familia'. Include their names, dates of birth, and relationship to you.
Complete the medical history section if applicable. Provide details about any recent hospital visits or medications taken by family members.
Finally, review all information for accuracy before signing and dating the form at the end. This ensures timely processing of your request.

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