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Get the free MSC 5504 PEBB Open Enrollment and Correction Form

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Office use only Self Participants Open Enrollment CorrectionApproved by:Approved date:Effective date:See the Summary Plan Description for more information on benefits at www.oregon.gov/OHA/PEBB. Submit
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Obtain the MSC 5504 PEBB Open form from the designated source.
02
Fill in your personal information accurately, including full name, address, contact details, and social security number.
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Provide any additional information required, such as dependents' details or specific health information.
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Review the filled-out form for completeness and accuracy before submitting.
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Sign and date the form as required to validate your submission.

Who needs msc 5504 pebb open?

01
Employees who are eligible for the PEBB Open enrollment program.
02
Individuals who want to make changes to their existing PEBB coverage.
03
New employees who need to enroll in the PEBB program for the first time.
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MSC 5504 PEBB Open is a form for employers to report information about the health coverage they offer to their employees.
Employers who offer health coverage to their employees are required to file MSC 5504 PEBB Open.
Employers can fill out MSC 5504 PEBB Open by providing required information about the health coverage offered to employees.
The purpose of MSC 5504 PEBB Open is to collect data on the health coverage offered by employers to employees.
Employers must report information on the health coverage offered, number of employees covered, and other relevant details on MSC 5504 PEBB Open.
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