Aetna Medicare Advantage Form

Personal Information

To enroll in Aetna Medicare Advantage, please provide all the requested information in the form below, sign, and click submit when done.

Prospective member name*

Effective date:*

Former employer/union/trust information

Class Code*

800
801

Are you enrolled in another Medicare Advantage plan?

Yes
No

Name of insurance company*

This field is hidden when viewing the form

Phone Number

Tell us your provider

Full name of your PCP (first and last name)*

Are you a current patient?*

Yes
No

Provider ID (located in the provider directory):*

Primary Care ID (located in the provider directory):*

Your information

Last Name*

First Name*

Middle Initial

Birth Date*

Sex*

M
F

Phone Number*

Is this a mobile number*

Yes
No

Email address*

Permanent Residence Street Address (P.O Box is not allowed)*

City*

State*

Zip code*

County*

Mailing Address (Only if different from your Permanent Resident Address)*

Yes
No

Address*

City*

State*

Zip code*

Please Provide Your Medicare Insurance Information as it appears on your card.

Medicare Number*

You must have Medicare Part A and Part B to join a Medicare Advantage plan.

Effective Date HOSPITAL (Part A)*

Effective Date MEDICAL (Part B)*

Please read and answer these important questions:

Are you the retiree?*

Yes
No

Retirement Date*

Name of Retiree:*

Are you covering a spouse or dependents under this employer, trust or union plan?*

Yes
No

Name of spouse*

Name(s) of dependent(s):*

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Dependent 1

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Dependent 2

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Dependent 3

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Dependent 4

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Dependent 5

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Dependent 6

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Dependent 7

Will you have other presciption drug converage in addition to the Aetna Medicare plan?*

Yes
No

Name of other coverage:*

ID # for this coverage:*

Group # for this coverage:*

Please tell us a litte more about yourself

Are you Hispanic, Latio/a, or Spanish origin? Select all that apply.

No, not of Hispanic, Latino/a, or Spanish origin
Yes, Puerto Rican
Yes, another Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Cuban
I choose not a answer.

What's your race? Select all that apply.

Indicate your preferred Spoken language (if not English):

Spanish
Other

Other language type

Indicate your preferred written language (if not English):

Spanish
Other

Other language type

Signature*

Today's Date*

If you're the authorized representative, you must sign above and provide the following information.

Representative's name

Address

Phone number

Email Address

Relationship to enrollee