67466-14 doc 2025

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The document is an application update for Aetna Advantage Plans, informing parents and guardians about compliance with the Affordable Care Act regarding dependent coverage up to age 26. It outlines the application process, required information, and health history questions for applicants and their dependents. Additionally, it highlights the option to choose a Consumer Choice Benefit Plan that may offer fewer state-mandated health benefits in Texas. The document includes instructions for completing the application, payment options, and important disclaimers regarding coverage approval.

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Click ‘Get Form’ to open the 67466-14 document in the editor.
Begin by filling out Section A, 'Applicant Information.' Ensure you provide your full name, mailing address, and contact numbers clearly. Remember to use blue or black ink if printing.
In Section B, list all individuals covered under the plan. Include their names, social security numbers, dates of birth, and other required details.
Proceed to Section C to confirm dependent information. Answer whether all children listed are unmarried and provide any necessary details.
Complete Sections D and E regarding other insurance coverage and health history. Be thorough in your responses as missing information may delay processing.
Review Sections F through K for health-related questions and conditions. Provide complete details for any 'Yes' answers in Section G.
Finally, ensure that all signatures are obtained in Section L before submitting the application to Aetna Advantage Plans at the provided address.

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