To enroll, carefully review the information in this section and check the box:
I ELECT TO ENROLL in (or MAKE CHANGES TO) a health benefits plan as indicated above and agree to authorize deductions from
my salary to cover my share of the cost of enrollment as it is now or as it may be in the future. I CERTIFY that the information
provided herein is accurate and listed dependents are eligible family members as defined in the Public Employees' Medical and
Hospital Care Act.
I VOLUNTARILY enroll into the selected Health Plan. I AGREE to read the associated Evidence of Coverage (EOC) and any
subsequent EOC's in the following years to understand the benefits of the plan. The Subscriber and all eligible dependents agree to all
of the terms and conditions of the EOC and the Health Plan.
I UNDERSTAND that enrolling in certain health plans requires binding arbitration and that any dispute as to medical malpractice, that
is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently,
or incompetently rendered, will be determined by submission to arbitration as provided by California Law and not by a lawsuit or resort
to court process except as California las provides for judicial review of arbitration proceedings. The parties to this agreement, by
entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury and instead are
accepting the use of arbitration.
To decline, carefully review the information in this section and check the box:
I DECLINE ENROLLMENT into the CalPERS Health Program and/or the CSU Dental program for myself and/or my dependents.
I UNDERSTAND that if I choose to enroll later, I must wait at least 90 days after I request enrollment or until the next Open
Enrollment (OE) period before enrolling in the CalPERS Health Program and/or CSU Dental program. Furthermore, if I or my
dependents involuntarily lose other health/dental insurance coverage, I may request enrollment into either Program within 60 days
from the date of lost coverage. If I do not request enrollment within 60 days, I must wait at least 90 days or until the next OE period
before I can enroll. The effective date of coverage will be the first of the following month following the 90 day wait period or the OE
effective date.
Employee Signature Benefits Officer’s Signature
Date
Privacy Information
Date
Submission of the requested information is mandatory. The information requested is collected pursuant to the California Government Code
(sections 20000 et seq.) and is used for administration of the CalPERS Board's duties under the Public Employees' Retirement Law, the
Social Security Act, and the Public Employees' Medical and Hospital Care Act, as the case may be. Portions of this information may be
transferred to other governmental agencies (such as your employer), physicians and insurance carriers but only in strict compliance with
current statuses regarding confidentiality. Failure to supply the information may result in CalPERS being unable to perform its function
regarding your status.
You have the right to review your CalPERS membership files. For questions concerning your rights under the Information Practices Act of
1977, please contact the CalPERS Customer Contact Center at 1-888-CalPERS (or 1-888-225-7377).
Section 7(b) of the Privacy Act of 1974 (Public law 93-579) requires that any federal, State or local governmental agency requesting an
individual to disclose a Social Security account number to inform the individual whether that disclosure is mandatory or voluntary, by which
statutory or other authority such number is solicited, and what uses will be made of it. Section 111 of Public Law 101-173 requires group
health plans to collect and provide member Social Security numbers for the coordination of federal and State benefits. Furthermore, the
CalPERS health program requires each enrollee's Social Security number for identification purposes and to verify eligibility for benefits.
The CalPERS health program and CSU Dental plan uses Social Security numbers for the following purposes:
1.
Enrollee identification for eligibility processing and eligibility verification
2.
Payroll deduction and State contribution for State employees
3.
Billing of contracting agencies for employee and employer contributions
4.
Reports to CalPERS and other state agencies
5.
Coordination of benefits among health plans
6.
Resolution of member complaints, grievances and appeals with health plans
IMPORTANT: It is your responsibility to notify the Benefits Services department when there are any changes in your family situation.
Changes include domestic partnership termination, establishment of a parent-child relationship, acquisition of a dependent child, changes of
address, marriage, divorce, legal separation and death. Failure to notify the Benefits Services department may result in adverse
consequences.
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
