Fillable Opm2810 Notice of Change in Health Benefits Enrollment

Fill Online, Printable, Fillable, Blank Opm2810 Notice of Change in Health Benefits Enrollment Form

Use Fill to complete blank online U.S. OFFICE OF PERSONNEL MANAGEMENT (GA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Opm2810 Notice of Change in Health Benefits Enrollment

On average this form takes 14 minutes to complete

The Opm2810 Notice of Change in Health Benefits Enrollment form is 3 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 54 other fields

Country of origin: US
File type: PDF

U.S.A. forms for U.S. Office of Personnel Management

BROWSE U.S. OFFICE OF PERSONNEL MANAGEMENT (GA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Federal Employees
Health Benefits Program
Notice of Change in Health Benefits Enrollment
Part A - Identifying Information
2. Annuity Claim
CSA
3. Survivor Annuity Claim
CSF
5. Social security number 4. Date of birth (mm/dd/yyyy)
7. Payroll office number
24 90 0002
8. Enrollment code
11. Date this action becomes
effective (mm/dd/yyyy)
10. Enrollment I.D.
1. Name (last, first, middle initial)
6. Address (including ZIP
Code)
9. Email
Only the items checked below affect your enrollment. Read that item carefully and follow any pertinent instructions. Keep this form for your records.
Part B - Termination
Your enrollment terminates on the date in Part A, item 11, above. However, your coverage is extended for 31 days after that date.
Important Notice: You have the right to convert to an individual (non-group) contract with the carrier of your plan. See Part B - Termination
on the back of this form for information about 31-day extension of coverage and conversion.
Part C - Transfer In Part D - Reinstatement
Your Federal retirement system has accepted transfer of this
enrollment and will continue it.
Your enrollment has been reinstated effective on the date in Part A,
item 11, above.
Part E - Change in Name of Enrollee Part F - Change in Enrollment - Survivor Annuitant
The name under which this enrollment is carried has been
changed to:
Note: The Plan will send you a new identification card.
Your enrollment has been changed from Self and Family coverage to
Self Only coverage. Your Plan will send you a new identification card.
Your enrollment has been changed from Self and Family coverage to
Self Plus One. Your plan will send you a new identification card in
your names.
Your enrollment has been changed from Self and Family coverage to
Self Only. Your plan will send you a new identification card in your
name.
Your enrollment has been changed from Self Plus One to Self Only.
Your plan will send you a new identification card in your name.
New enrollment code number
Name Date of birth (mm/dd/yyyy)
Address (including ZIP Code) if different from Part A, item 6, above.
Social security number Sex
Male Female
Part G - Remarks
Date of Death (if applicable)
Part H - Date of Notice
Name and address of agency
U.S. Office of Personnel Management, Retirement Services, Washington, DC 20415
(For agency use only)
Signature of authorized agency official Date (mm/dd/yyyy)
OPM Form 2810
Revised December 2017
Previous editions are not usable
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices
PRINT
CLEAR
SAVE
Copy 1 - To Enrollee
Part B - Termination
If Part B on the other side of this form is checked, read the following instructions carefully.
31-Day Extension of Coverage
Your enrollment terminates on the date shown in Part A, item 11, on the
front of this form. Coverage under your enrollment continues for 31 days
from the date shown. If you, or any covered member of your family, are a
patient in a hospital on the 31st day of this extension, benefits of the plan
may continue for the rest of that confinement, but not beyond 60 more days.
Conversion to Non-group Contract
You may convert your enrollment to a non-group contract, without evidence
of good health. The non-group contract to which you may convert is one
regularly offered by your plan. It may differ from your group plan in
benefits or cost, or both, and you will have to pay the entire cost of the
non-group contract directly to the plan. The non-group contract is effective
on the day after your 31-day extension of coverage ends.
If you are interested in converting to a non-group contract, write for
information to the nearest office of the plan in which you have been enrolled
(see the plan's brochure or ask the Office of Personnel Management for the
address of the plan's nearest office). The plan will promptly send you an
application form and details concerning benefits and rates of the non-group
contract to which you may convert.
Time Limit on Conversion
Normally, to be eligible for conversion, you must send your written request
for information to your plan within 31 days after the date shown in Part H.
However, if the date shown in Part H is more than 60 days after the date your
enrollment terminates (Part A, item 11), you must forward your written
request to your plan within 91 days after the date shown in Part A, item 11.
If you are prevented by causes beyond your control from submitting a
timely request for information about conversion to a non-group contract,
you should write to your plan as soon as possible asking approval of a
belated conversion opportunity.
Explain fully the circumstances that prevented earlier action and attach a
copy of this form or other proof of loss of group coverage.
A plan may consider requests filed within 6 months after group eligibility
ends. If your plan needs assistance in processing your request, it should
contact OPM.
Help in Obtaining Insurance through the Marketplace
In lieu of offering a non-FEHB plan for conversion purposes, your plan will
offer assistance to you in obtaining health benefits coverage inside or
outside the Affordable Care Act's Health Insurance Marketplace. For
assistance in finding coverage, please contact your plan directly.
Entry on Active Military Duty
If you elected to terminate your enrollment because you are entering military
service, you may convert to a non-group contract even though your family
members are entitled to care under the Uniformed Services Health Benefits
Program. Your enrollment will be reinstated on the day you are separated
from military service. You must notify your retirement system of this event
by furnishing a copy of your separation papers.
If Part C, D, E, or F on the other side of this form is checked, read carefully whichever of the following instructions applies.
Part C - Transfer of Enrollment
Retirement - Your enrollment continues automatically during retirement
because you met certain eligibility requirements.
Death - If the deceased employee or annuitant was enrolled for self and
family at the time of death, and if at least one of the covered family
members is entitled to survivor annuity (or the surviving spouse is eligible
for FERS Basic Employee Death benefit), eligible family members who
were covered by the enrollment of the deceased may continue the coverage.
The health benefits plan identification number generally is the deceased's
social security number.
Part D - Reinstatement
This form is used to reinstate your health benefits enrollment.
The enrollment may have been terminated because your annuity was
terminated, because you entered military service and elected to terminate
your enrollment, or because of an error or misunderstanding.
Part E - Change in Name of Enrollee
At the time a Federal retirement system survivor annuity is approved, this
form is used to show that the retirement system has continued the health
benefits enrollment in the survivor's name. If an eligible spouse survives,
the enrollment will be changed to his/her name. Otherwise, the enrollment
will be continued in the name of the youngest child.
Part F - Change in Enrollment - Survivor Annuitant
The enrollment will remain in the family option unless there is only one
eligible family member. In that event, the enrollment will be changed to the
self-only option. The family plan covers all eligible family members. Any
time the person who is paying for the family enrollment elects to change to
self-only, all other eligible family members will be given an opportunity to
enroll in an FEHB plan.
Keep This Form For Your Records.
Back, Copy 1
OPM Form 2810
Rev
ised December 2017
Federal Employees
Health Benefits Program
Notice of Change in Health Benefits Enrollment
Part A - Identifying Information
5. Social security number 4. Date of birth (mm/dd/yyyy)
8. Enrollment code
11. Date this action becomes
effective (mm/dd/yyyy)
10. Enrollment I.D.
1. Name (last, first, middle initial)
6. Address (including ZIP Code)
9. Email
7. Payroll office number
24 90 0002
3. Survivor Annuity Claim
CSF
2. Annuity Claim
CSA
Only the items checked below affect your enrollment. Read that item carefully and follow any pertinent instructions. Keep this form for your records.
Part B - Termination
Your enrollment terminates on the date in Part A, item 11, above. However, your coverage is extended for 31 days after that date.
Important Notice: You have the right to convert to an individual (non-group) contract with the carrier of your plan. See Part B - Termination
on the back of this form for information about 31-day extension of coverage and conversion.
Part C - Transfer In Part D - Reinstatement
Your Federal retirement system has accepted transfer of this
enrollment and will continue it.
Your enrollment has been reinstated effective on the date in Part A,
item 11, above.
Part E - Change in Name of Enrollee Part F - Change in Enrollment - Survivor Annuitant
The name under which this enrollment is carried has been
changed to:
Note: The Plan will send you a new identification card.
Your enrollment has been changed from Self and Family coverage to
Self Only coverage. Your Plan will send you a new identification card.
Your enrollment has been changed from Self and Family coverage to
Self Plus One. Your plan will send you a new identification card in
your names.
Your enrollment has been changed from Self and Family coverage to
Self Only. Your plan will send you a new identification card in your
name.
Your enrollment has been changed from Self Plus One to Self Only.
Your plan will send you a new identification card in your name.
New enrollment code number
Name Date of birth (mm/dd/yyyy)
Address (including ZIP Code) if different from Part A, item 6, above.
Social security number Sex
Male Female
Part G - Remarks
Date of Death (if applicable)
Part H - Date o f Notice
Name and address of agency
U.S. Office of Personnel Management, Retirement Services, Washington, DC 20415
Payroll contact and telephone number
OPM, Retirement Benefits, (202) 606-5148
Signature of authorized agency official
(For agency use only)
Date (mm/dd/yyyy)
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices
Copy 2 - To Insurance Carrier
OPM Form 2810
Revised December 2017
Previous editions are not usable
Instructions for the Retirement Services Offices
Purpose of Form
This form covers health benefits actions except enrollments, changes from one plan to another, changes of coverage within a plan, and cancellations, all of
which are processed on the Health Benefits Registration Form (OPM Form 2809). When an action requires a change in health benefits enrollment, prepare
OPM 2810 as soon as the effective date is known and dispose of copies as indicated below.
Prompt Action Required for Conversion
Send this form to the enrollee within 60 days after the date shown in Part A, item 11. To be eligible to convert to a non-group contract, the enrollee must send
a written request for information about conversion to a non-group contract to his or her plan within 31 days after the date shown in Part H, but not later than 91
days after the date shown in Part A, item 11.
Completion of Form
Part A - Identifying Information
1.
For items 1, 4, 5, 8, and 9, transcribe from the last SF or OPM 2809
or 2810, whichever is the most recent.
2. Item 6, use most recent known address.
3.
Item 11, date as follows for action reported in:
B.
Termination - Last day of month in which terminating event
occurs.
C. Transfer In - Actual date.
D. Reinstatement - Actual date.
E. Change In Name of Enrollee - Actual date.
F.
Change In Enrollment - Survivor Annuitant - Effective date of
sole survivor's annuity.
Part B - Termination
These most frequently occurring actions terminate enrollment with enrollee
eligible to convert to individual contract:
- Retired - not eligible to continue enrollment.
- Died - no survivor eligible to continue enrollment.
- Termination of title to annuity or compensation.
- Changed to excluded position or category.
- 365 days non-pay status completed.
- Temporary continuation of coverage expired.
Disposition
Copy 1 - Deliver (or mail) to annuitant or survivor.
Copy 2 - Send to Insurance Services Branch.
Copy 3 - File in case.
Part C - Transfer In
Gaining office uses this box to report transfer actions such as:
- Retired - Acceptance of the enrollment by retirement system because
employee is eligible to continue enrollment as an annuitant.
- Death - Acceptance of the enrollment by retirement system because
survivor is eligible to continue enrollment as a survivor annuitant.
Part D - Reinstatement
In Part G, "Remarks" give the reason for the reinstatement.
Part E - Change in Name of Enrollee
Use this box only for reporting changes in name where change of coverage
within a plan by OPM 2809 is not involved. Show date of birth only where
enrollment is changed from employee's or annuitant's name to name of
survivor annuitant.
Part F - Change in Enrollment - Survivor Annuitant
Claims examiners will make this determination on the basis of documentary
evidence that there is only one survivor annuitant.
Part G - Remarks
Use this box to bring to the attention of the annuitant or insurance carrier
any pertinent information to clarify or support the action being taken.
Part H - Date of Notice
Facsimile signature is acceptable. Date as day of issuance.
Back, Copy 3
Revised December 2017
Previous editions are not usable
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Opm2810 Notice of Change in Health Benefits Enrollment

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 November 2019

Message

View Audit Log
Print With Audit Log
Duplicate Document