Get the free CalPERS HEALTH ENROLLMENT FORM (HBD-12) Instructions
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You can contact the HMO plan to make changes or select a PCP for your dependents. 12 13 14 15 Effective Date List all family members as follows avoid nicknames Enrolled Family Members First Name full Middle abbreviation Last name full List birthdate s as MM/DD/YYYY List Social Security Numbers for dependents List gender of family member. Include Family Relationship Family Relationship Abbreviation Wife/Husband Spouse Domestic Partner DP Son/Daughter Child Stepson/Stepdaughter Stepchild...
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How to fill out calpers health enrollment form
How to fill out calpers health enrollment form
01
Start by downloading the CalPERS health enrollment form from their official website.
02
Read the instructions carefully to understand the requirements and necessary information.
03
Gather all the required documents such as identification proof, dependent information, and any other supporting documents.
04
Fill out the form accurately and legibly, providing all the requested information.
05
Make sure to include all the necessary signatures, both from the member and any applicable dependents.
06
Double-check the form to ensure that there are no errors or missing information.
07
Submit the completed form by the specified deadline through the preferred submission method, whether it is online, by mail, or in-person.
08
Keep a copy of the filled-out form for your records for future reference.
Who needs calpers health enrollment form?
01
Employees who are eligible to receive health benefits through the California Public Employees' Retirement System (CalPERS).
02
Retirees who are enrolled in a CalPERS health plan.
03
Dependents of eligible employees or retirees who are covered under the CalPERS health plan.
04
Newly hired employees who wish to enroll in the CalPERS health plan.
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What is calpers health enrollment form?
The CalPERS health enrollment form is a document used to enroll in health benefits through the California Public Employees' Retirement System.
Who is required to file calpers health enrollment form?
All eligible employees and retirees who wish to enroll in health benefits through CalPERS are required to file the health enrollment form.
How to fill out calpers health enrollment form?
To fill out the CalPERS health enrollment form, individuals must provide their personal information, select a health plan, and indicate any dependents they wish to enroll.
What is the purpose of calpers health enrollment form?
The purpose of the CalPERS health enrollment form is to enroll individuals and their eligible dependents in health benefits offered through CalPERS.
What information must be reported on calpers health enrollment form?
The health enrollment form requires personal information, health plan selection, and details of any dependents being enrolled.
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