Fillable Health-benefit-enroll-form HBD-12 Fillable Health Benefit Plan Enrollment Form

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Health-benefit-enroll-form HBD-12 Fillable Health Benefit Plan Enrollment Form

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The Health-benefit-enroll-form HBD-12 Fillable Health Benefit Plan Enrollment Form form is 1 page long and contains:

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  • 15 check-boxes
  • 34 other fields

Country of origin: US
File type: PDF

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Day
Mo. Day Year
(LAST)
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California Public Employees' Retirement System
P.O. Box 942715
Sacramento, CA 94229-2715
HEALTH BENEFIT PLAN
ENROLLMENT FORM DO NOT SEND MEDICAL
PERS-HBD-12 (Rev. 6/13) CLAIMS TO THIS ADDRESS
CalPERS
USE ONLY - DOCUMENT REFERENCE NUMBER
1. TYPE OF
ACTION
(Check One)
2. SOCIAL SECURITY NUMBER
PLEASE TYPE
LIST ALL PERSONS (including self)
TO BE ENROLLED IN:
DATE OF
BIRTH
Family
Relation-
ship
G
E
N
D
C
E O
R
D
4A.
a. NEW enrollment
b. CHANGE of coverage
c. CANCEL all coverage
3. SPOUSE/DOMESTIC PARTNER'S SOCIAL SECURITY
NUMBER
17. BASIC PLAN Mo. Day Yr.
(FIRST)
(MI)
(LAST)
SSN
SELF
F M
E
Name
Mailing
Address
City,
State, ZIP
(FIRST) (MI)
(LAST)
Daytime Phone Evening Phone
(FIRST)
(MI)
(LAST)
SSN
4B. RESIDENCE ZIP CODE
(If different from 4A)
(FIRST) (MI) (LAST)
5.
Please check if
Permanent Intermittent
Employee (applies to active
State employees only)
6. GENDER
Male
Female
7. MARRIED
Yes
No
SSN
(FIRST)
(MI)
(LAST)
8. PLAN CODE 9. NAME OF HEALTH PLAN
SSN
10. GROSS PREMIUM
$
12. PRIOR PLAN CODE
11. PRIMARY CARE PHYSICIAN/MEDICAL GROUP
13. PRIOR HEALTH PLAN
18. SUPPLEMENTAL PLAN
DATE OF BIRTH
Relation-
14. Reason Code
19. CHECK ONE
15. Permitting Event Date 16. EFFECTIVE DATE
Mo. Day Yr. Mo. Day Yr.
01
(FIRST) (MI) (LAST)
Mo. Day Yr.
ship
I DO NOT elect to enroll in a Health Benefits Plan under the Public Employees' Medical and Hospital Care Act.
I elect to ENROLL IN (OR CHANGE TO) a Health Benefits Plan as shown in Items 8 and 9 above and authorize deductions to be made from my
salary or retirement allowance to cover my share of the cost of enrollment as it is now or as it may be in the future. I also certify that the names of
all dependents listed above in items 17 and/or 18 are eligible family members as defined in the Public Employees' Medical and Hospital Care Act.
I elect to CANCEL the Health Benefits Plan as shown in items 12 and 13 above.
20. EMPLOYEE OR ANNUITANT'S SIGNATURE (see privacy information on reverse of employee copy)
21. DATE SIGNED
Mo. Day Year
TELEPHONE NUMBER ( )
PLEASE REFER TO THE HEALTH BENEFITS PROCEDURE MANUAL FOR COMPLETION OF ITEMS 22-27
22. DEDUCTION
PLAN CODE
28. AGENCY NAME (or Retirement System)
32. I hereby certify under penalty of perjury as
follows:
24. PAY PERIOD
Month
Year
25. PARTY CODE
29. PAYROLL OFFICE CODE
26. EMPLOYEE
DESIGNATION
30. AGENCY CODE
27. BARGAINING UNIT
31. UNIT CODE
New
Cancel
Change
1.
2.
3.
23.Type of
action
(Check One)
33. Date received in
employing office
34. PHONE NUMBER
35. REMARKS
___________ of__________ Forms
WHITE – HB PINK – Agency BLUE - Employee
That I am a duly appointed, qualified and acting officer
of the above named agency, and that payment by the
agency as provided by Sections 22870-22905 of the
Government Code is hereby approved. Final determina-
tion 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.
PRIVACY INFORMATION
Submission of the requested information is mandatory. The information requested is collected
pursuant to the California Government Code (sections 20000 et seq.) and will be used for
administration of the Board’s duties under the 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 another governmental agency (such as your employer) but only
in strict accordance with current statutes regarding confidentiality. Failure to supply the
information may result in the System being unable to perform its functions regarding your status.
You have the right to review your membership files maintained by the System. For questions
concerning your rights under the Information Practices Act of 1977, please contact the
Information Practices Act Coordinator, CalPERS, P.O. Box 942702, Sacramento, CA 94229-
2702.
Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or
local governmental agency which requests an individual to disclose his Social Security account
number shall inform that 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, Health Account
Services requires each enrollee’s Social Security number for identification purposes and to verify
eligibility for benefits. Specifically, the California Public Employees’ Retirement System 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 the Public Employees’ Retirement System and other state agencies.
5. Coordination of benefits among carriers.
BINDING ARBITRATION
Enrollment in certain plans constitutes an agreement to have any issue of medical malpractice
decided by neutral arbitration and waiver of any right to a jury or court trial. Refer to the health
plan Evidence of Coverage booklet to determine if this provision is applicable to your plan.
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Health-benefit-enroll-form HBD-12 Fillable Health Benefit Plan Enrollment Form

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Completed 1 July 2020

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