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 statutes regarding confidentiality. Failure
to supply the information may result in CalPERS being unable to perform its functions 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 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 your personnel office 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, change of address, marriage, divorce, legal
separation, and death. Failure to notify your personnel office may result in adverse consequences.
SECTION H: For Employer Use
Please retain original signed form and all supporting documentation or affidavits in employee file. DO NOT send to CalPERS.
I hereby certify under the penalty of perjury that I am a duly appointed, qualified and acting Health Benefits Officer (HBO) of the above named agency, and the
payment by the agency as provided by Section 22870-22905 of the Government Code is hereby approved. Final determination of eligibility for the enrollment
action specified will be made by the Board of Administration, Public Employees' Retirement System, in accordance with the Public Employees' Medical and
Hospital Care Act and the regulations implementing the Act.
The privacy of personal information is of the
utmost importance to CalPERS. The following
information is provided to you in compliance with
the Information Practices Act of 1977 and the
Federal Privacy Act of 1974.
The information requested is collected pursuant
to the Government Code Sections (20000
et seq.) and will be used for administration of
Board duties under the Retirement Law, the
Social Security Act, and the Public Employees'
Medical and Hospital Care Act, as the case may
be. Submission of the requested information is
mandatory. Failure to comply may result in the
system being unable to perform its functions
regarding your status.
Please do not include information that is not
SECTION F: CalPERS Privacy Notice
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS
first request for disclosure of your SSN, then
disclosure is mandatory. If your SSN has already
been provided, disclosure is voluntary. Due to the
use of Social Security numbers by other agencies
for identification purposes, we may be unable to
verify eligibility for benefits without the number.
Social Security numbers are used for the following
1. Enrollee identification
2. Payroll deduction / state contributions
3. Billing of contracting agencies for employee /
4. Reports to the CalPERS system and other
5. Coordination of benefits among carriers
6. Resolve member appeals, complaints, or
grievances with health plan carriers
Portions of this information may be transferred to
other state agencies (such as your employer),
physicians, and insurance carriers, but only in
strict accordance with current statutes regarding
You have the right to review your membership
files maintained by the system. For questions
rights, please write the CalPERS Privacy Officer
at 400 Q Street, Sacramento, CA 95811 or call
our Customer Contact Center at 888-CalPERS
SECTION G: Privacy Information
Date of Hire:
CalPERS Employer ID:
Employee Bargaining Unit/Employee Group:
Date Received by Employer:
Health Benefits Officer: (Print name)
HBD-12 (Rev 01/2018) Page 2 of 2