CALIFORNIA STATE UNIVERSITY, FRESNO
HEALTH BENEFITS WORKSHEET - FAMILY STATUS CHANGE
Employee’s Legal Name Fresno State ID: Staff/Administrator Faculty
Mailing Address (street, city, state, zip) Update new address at MyFresnoState (Self-Service) or Payroll Services.
Email
Home/Cell Phone
Section 1: Type of Transaction – Check one (Election/Change must be made within 60 days of event.)
Change – Add Eligible Dependent(s) (Documentation required)
Event (i.e., marriage, birth, adoption, economically dependent child)
Type of Event: Date:
Change – Delete Dependent(s) (Documentation required)
Event (i.e. divorce, legal separation, death, cancel dependents)
Type of Event: Date:
Change – Move (Address change must be made with Payroll Services / Election must be made within 60 days of event)
Date of event:
Change - Date of Loss or Gain of alternate coverage:___________________ (Documentation required)
ENROLL in Health Plan(Medical/Dental) & Cancel FlexCash
ENROLL in FlexCash & CANCEL Health Plan(Medical/Dental)
Section 2: Medical Plan Options – Check plan selected
RELATIONSHIP
CODE
SSN
Medical Dental
DATE OF BIRTH CIRCLE ACTION
SELF F M Add Delete
No Change
Add Delete
F M
F M Add Delete
F M
Add Delete
F M
Add Delete
F M Add Delete
S or DP
no yes
agency:
Basic
Vision
If spouse or domestic partner is employed or retired from CSU system, State civil service,
CalPERS Public Agency/School or CALSTRS are you a dependent on their health plans?
LEGAL - NAME (FIRST, M.I., LAST)
CIRCLE
Gender
Anthem Blue Cross
Select* (HMO)
Anthem Blue Cross
Traditional* (HMO)
BlueShield Access+
Advantage*(HMO)
Health Net
SmartCare* (HMO)
Kaiser* (HMO)
United HealthCare
Alliance* (HMO)
PERSChoice(PPO)
PERS Select(PPO) PERS Care(PPO)
PORAC (PPO) This medical plan is restricted to Unit 8 employees with SUPA membership.
Section 3: FlexCash Option (Cash payment in exchange for waiving CSU medical and/or CSU dental )
COPY OF PROOF OF ALTERNATE NON-CSU COVERAGE REQUIRED
Section 4: Dental Plan Options – Check plan selected
DELTA DENTAL (PPO)
DELTA CARE USA (HMO) Specify provider name and facility:_______________________________
• ADDING DEPENDENTS or SPOUSE/DOMESTIC PARTNER: ATTACH APPROPRIATE DOCUMENTS
• A Certificate of Live Birth and Social Security number are required for each eligible dependent.
• Marriage Certificate or Declaration of Domestic Partnership
• ADDING NEWBORN:
A Hospital Record of Birth for initial enrollment. A County Certificate of Live Birth and Social Security number will be required within 4-6 weeks of birth to complete enrollment.
• CHANGES: List all currently enrolled dependents for all plans (including yourself) then circle “Add” or “Delete” or “No Change”
No Change
No Change
No Change
No Change
No Change
Section 6: Enrollment - To enroll/decline, carefully review the information in this section and check the box:
Date: (mm/dd/yyyy)
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 EOCs in the following
years to understand the benefits of the plan. The Subscriber and all eligible dependents agree to all 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 law 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.
I DECLINE ENROLLMENT into the CalPERS Health Program for myself and my dependents.
I UNDERSTAND that
if I choose to enroll at a later date, 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. Furthermore, if I or my dependents involuntarily lose other health insurance coverage, I may request enrollment
into the 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 month following the 90 day waiting period or the OE effective date.
Employee Signature:
Use Work ZIP Code for Health Eligibility?
No Yes, ZIP :
Rev 5/2018
*
Relationship Codes:
S - Spouse DP - Domestic Partner NC - Natural Child SC - Step Child AC - Adopted Child DPC - Domestic Partner Child PCR - Parent Child Relationship
This document must be received by Human Resources, Joyal Admin., Room 211, (559) 278-2032 within 60 days of Family Status Event.
Section 5: IMPORTANT INFORMATION FOR NEW ENROLLMENTS AND CHANGES
I elect to enroll in FlexCash for: Health only ($128/mo) Dental only ($12/mo) Health & Dental ($140/mo)
