Step 1 of 2: Medical profile   Gender Date of birth Height Weight Smoker? Applicant* M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Spouse -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children 0  1 2 3 4 5 6         Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Currently Insured?* Yes No Have conditions?* yes   no Please specify  Take medications?* yes   no Please specify  Step 2 of 2: Tell us about yourself First Name* Last Name* Address* City* State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip* Day Phone* Evening Phone* Contact Time* Morning Afternoon Evening Email* By submitting this form, you agree to be legally bound to, and abide by, the Privacy Policy.

Small Business HMO Providers

HMO
In the HMO plan, members choose a participating primary care physician/provider (PCP) to manage care and make referrals. For each visit, members pay a copayment.

Open Access HMO
Aetna's Open Access™ plan provides your employees with greater freedom of choice in accessing health care. Open Access is similar to the HMO plan except referrals are not required to visit a network provider for covered services. Members have the option to see their PCP and pay a copayment, or go directly to network specialists without a PCP referral and pay the specialist copayment.

CIGNA

CIGNA HealthCare HMO
CIGNA HealthCare HMO gives your employees the highest level of care management and cost control. In addition, a wide range of wellness programs is offered such as informative publications, low-cost or no-cost preventive care, and valuable discounts on health and fitness-related services.

CIGNA HealthCare Network Plan
The HealthCare Network Plan is just like a traditional HMO where members choose a primary care physician to manage all of their care. Features include predictable out-of-pocket costs, virtually no paperwork, and coverage for emergency and urgent care, 24 hours a day, anywhere in the world.

UNITEDHEALTHCARE

UnitedHealthcare Choice and Choice Plus:
UnitedHealthcare Choice and Choice Plus provide the freedom to visit any physician, even specialists, without a referral. It is recommended but not required to have a primary care physician to coordinate health care.

UnitedHealthcare Choice and Choice Plus Highlights:

• Go to any physician
• Visit specialists without a referral
• Low copayments
• Little or no out-of-pocket costs for network care
• No claim forms or bills for network care

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