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County of Kern Retiree Health Plans 2017 Open Enrollment Request for Dis-Enrollment PLEASE PRINT Effective Date 01/01/2017 RETIREE/MEMBER LAST NAME FIRST M. I. SOCIAL SECURITY NUMBER ADDRESS CITY STATE ZIP TELEPHONE DATE OF BIRTH MEDICARE NO. if different from Social Security Number I wish to dis-enroll from OR COUNTY Dis-enrollment does NOT apply to member Dis-enrolling dependent only From the following Health plan Point-Of-Service POS Plan Health Net Managed Care Systems EPO Plan Kaiser...

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County of Kern retiree is a form that needs to be filled out by retired employees of Kern County in California.

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Retired employees of Kern County are required to file the county of kern retiree form.

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