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Enrolling in any of the plans is simple. Once you have reviewed all of the information for each plan, which is found under the appropriate benefit offered on this website as medical, dental, vision or life, simply click on the appropriate enrollment form in this section, print it, then complete and sign the form. See below for instructions on submitting your enrollment form(s).
Medical, Dental, and Vision Plan Enrollment
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The Aetna Enrollment Form is to be used for enrolling in any of the medical, dental or vision plans and for making changes once you are enrolled. Instructions on how to complete the form are also attached. Please Note – You have four medical plan options; 1) Aetna Value Network HMO, 2) Aetna Full Network HMO, 3) Aetna Open Access Managed Choice POS PPO or 4) Aetna Open Access Managed Choice POS HSA (Please note the HSA plan is called a "PPO - High Deductible Health Plan" on the enrollment form) . Please complete the form in its entirety and sign/date it where indicated.
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Life Insurance Plan Enrollment
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If you would like to to enroll in the life insurance plan, please use the Aetna Enrollment Form.
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2017 Premium Contributions
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In order to view the per-pay-period deduction amounts for the medical, dental and vision plans, please click on 2017 Premium Contributions. If you choose to enroll in any of the plans, please print, complete and sign the form and submit to Human Resources.
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Waiving the Plans- Completing the Declination Form
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If you are covered by another plan(s) or simply choose to not enroll in any, or all, of the benefit plans offered, please complete the Declination Form in the appropriate sections. Please note that when you are covered by another health plan and decline coverage, if the other coverage is lost, you may qualify to enroll in the Office Solutions benefit plans. In order to do so, you would need to provide a letter from either the previous carrier or other employer providing the coverage, stating the type of coverage and the date coverage was lost. You must complete and submit the enrollment form(s) for the coverage you desire within 30 days of the loss of coverage in order to be eligible for the plans. Failure to do so would disallow enrollment until the next open enrollment period.
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Changing Your Enrollment
Once you have made your benefit plan decisions, you cannot change your enrollment until open enrollment for the following benefit plan year, unless you experience a qualifying (life) event, such as marriage, divorce, birth of a child, adoption of a child or placement for adoption. If you experience a qualifying event and wish to make a change to your enrollment by adding or deleting coverage, the change must occur within 30 days of the date of the qualifying event.
If you have experienced a qualifying event, in order to make a change to your medical enrollment, you would use either of the enrollment/change forms, depending on whether you are enrolled in one of the HMO plans, or the POS plan. These forms allow you to add or delete eligible dependents, as well as indicate other changes, as a name, address or Primary Care Physician change.
If you have experienced a qualifying event, in order to make a change to your medical enrollment, you would use either of the enrollment/change forms, depending on whether you are enrolled in one of the HMO plans, or the POS plan. These forms allow you to add or delete eligible dependents, as well as indicate other changes, as a name, address or Primary Care Physician change.
Questions?
For questions about claims, please click on Important Plan/Contract Information under the appropriate line of coverage for the customer service contact number.
For questions regarding plan eligibility, benefits or enrollment forms, contact Thomas Lambert at Ashbrook Clevidence.
Phone: (714) 979-4023
Fax: (714) 979-2809
Email: TomL@aclevidence.com
We thank you for the opportunity to be of service to you and your family!
For questions regarding plan eligibility, benefits or enrollment forms, contact Thomas Lambert at Ashbrook Clevidence.
Phone: (714) 979-4023
Fax: (714) 979-2809
Email: TomL@aclevidence.com
We thank you for the opportunity to be of service to you and your family!
