Get the free LAPRA MedicalDental EnrollmentChange Form - Los Angeles bb - lapra

Medical / Dental Plan Enrollment & Change Form For office use only Effective Date: SECTION 1 Group Number: Fund Code: Part Code: ACTION REQUESTED New Enrollment (Active) New Enrollment (Retiree) Open

How to fill out lapra medicaldental enrollmentchange form

How to fill out the LAPRA medical/dental enrollment/change form:

1. Obtain the form: Contact your employer or the LAPRA office to obtain a copy of the medical/dental enrollment/change form. They may provide it in a physical format or have it available for download on their website.
2. Personal information: Fill out the required personal information section of the form. This typically includes your full name, address, contact number, email, and employee identification number.
3. Select medical/dental plan: Review the available medical and dental plans provided by LAPRA. Choose the plan that best suits your needs, and indicate your selection on the form. Some plans may require you to select separate medical and dental options.
4. Dependents: If you have dependents that you would like to add or remove from your coverage, provide their relevant information in the designated section. This may include their full name, relationship to you, and their Social Security numbers.
5. Beneficiary designation: In the case of your passing, it is important to designate a beneficiary to receive any applicable benefits. Indicate the name, relationship, and contact details of your chosen beneficiary in the appropriate section of the form.
6. Signature and date: Ensure that you sign and date the form in the designated areas. This signifies your acknowledgment and agreement to the terms and conditions outlined in the enrollment/change form.

Who needs the LAPRA medical/dental enrollment/change form?

1. LAPRA members: Any member of LAPRA who wishes to enroll in or make changes to their medical and dental coverage needs the enrollment/change form. This may include new LAPRA members, existing members seeking to make alterations, or those who have experienced a change in their personal or dependent circumstances that warrants an update in their coverage.
2. Dependents: If you have dependents who are eligible for LAPRA medical and dental coverage, they may also need to complete the form, especially if they are adding or removing individuals from their coverage.
3. Human resources or benefits department: Employers who offer LAPRA medical and dental coverage to their employees may require the completion of the enrollment/change form. The human resources or benefits department of these employers may need to process the form to update the employee's coverage effectively.

Note: It is essential to carefully review the instructions provided on the form or consult with the LAPRA office if you have any questions or need clarification on specific sections.

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What is lapra medicaldental enrollmentchange form?

The lapra medicaldental enrollmentchange form is a document used to make changes to medical or dental enrollment information with LAPRA.

Who is required to file lapra medicaldental enrollmentchange form?

Employees or members who need to update their medical or dental enrollment information with LAPRA are required to file the form.

How to fill out lapra medicaldental enrollmentchange form?

The form should be filled out with the necessary updated information regarding medical or dental enrollment changes and submitted to LAPRA.

What is the purpose of lapra medicaldental enrollmentchange form?

The purpose of the form is to ensure that LAPRA has accurate and up-to-date medical or dental enrollment information for its members.

What information must be reported on lapra medicaldental enrollmentchange form?

The form typically requires the reporting of changes to medical or dental enrollment information, such as a change in coverage level or adding or removing dependents.