MEDICAL ENROLLMENT FORM SAN JOSE STATE UNIVERSITY

SAN JOSE STATE UNIVERSITY RESEARCH FOUNDATION
MEDICAL ENROLLMENT FORM
New
Open Enrollment
Cancel
Waive
Change:
Add Dependent
Delete Dependent
Change Plan
Name
SSN
Address
Email
Home Phone
Gender
Married
Work Phone
If Yes, Marriage Date
Medical Plan Choice
HMO
PPO
List all persons (including yourself) to be enrolled in your health insurance plan.
Name
Gender
Relationship
Social Security Number
Date of Birth
Self
(Please use the backside if more space is needed)
Are you or other family members currently enrolled in another PERS plan?
Yes
No
I elect to enroll in (or change to) the plan shown above and authorize a deduction (if any applies) to be made from my salary to
cover my share of the cost as it is now or as it may be in the future.
Signature
Date
For HR Use Only
Plan Code
Permitting Event Date
Rev. July 2016
Plan Name
Effective Date
Gross Premium
HR Approval
California Public Employees' Retirement System
P.O. Box 942714
Sacramento, CA 94229-2714
HEALTH BENEFIT PLAN
ENROLLMENT FORM
DO NOT SEND MEDICAL
CLAIMS TO THIS ADDRESS
PERS-HBD-12 (Rev.8/10)
 PLEASE TYPE
2. SOCIAL SECURITY NUMBER
1. TYPE OF ACTION
(Check One)
a. NEW enrollment
3. SPOUSE/DOMESTIC PARTNER'S SOCIAL SECURITY
NUMBER
b. CHANGE of coverage
c. CANCEL all coverage
A
CC
TO
I D
OE
N
17. BASIC PLAN
Mo. Day Yr.
(MI)
(LAST)
(MI)
(LAST)
(MI)
(LAST)
(MI)
(LAST)
G
E
N
D
E
R
Family
Relationship
M
F
C
O
D
E
SELF
SSN
Name
(FIRST)
(MI)
(LAST)
(LAST)
City,
State, ZIP
Daytime Phone
4B. RESIDENCE ZIP CODE
5.
DATE OF
BIRTH
LIST ALL PERSONS (including self)
TO BE ENROLLED IN:
(FIRST)
4A.
Mailing
Address
CalPERS USE ONLY - DOCUMENT REFERENCE NUMBER

Please check if
Permanent Intermittent
Employee (applies to active
State employees only)
Evening Phone
SSN
(FIRST)
(If different from 4A)
6. GENDER
Male
Female
7. MARRIED
Yes
No
SSN
(FIRST)
8. PLAN CODE
9. NAME OF HEALTH PLAN
10. GROSS PREMIUM
$
11. PRIMARY CARE PHYSICIAN/MEDICAL GROUP
12. PRIOR PLAN CODE
13. PRIOR HEALTH PLAN
14. Reason Code
(FIRST)
SSN
15. Permitting Event Date 16. EFFECTIVE DATE
Mo.
Day
Yr.
Mo.
Day
01
A
CC
TO
I D
OE
N
18. SUPPLEMENTAL PLAN
(FIRST)
(LAST)
C
O
D
E
Relationship
DATE OF BIRTH
(MI)
Mo. Day Yr.
Yr.
19. CHECK ONE
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
TELEPHONE NUMBER (
)

 PLEASE REFER TO THE HEALTH BENEFITS PROCEDURE MANUAL FOR COMPLETION OF ITEMS 22-27
22. DEDUCTION
PLAN CODE
23. Type of
action
Check
One
(
)
1.
2.
3.
New
Cancel
Change
24. PAY PERIOD
Month
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 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.
26. EMPLOYEE
DESIGNATION
27. BARGAINING UNIT
29. PAYROLL OFFICE CODE
30. AGENCY CODE
31. UNIT CODE
Year
28. AGENCY NAME (or Retirement System)
32. I hereby certify under penalty of perjury as follows:
25. PARTY CODE
SIGNATURE OF HEALTH BENEFITS OFFICER
33. Date received in
employing office
Mo.

Day
Year
34. PHONE NUMBER
(
35. REMARKS
of
Forms
WHITE - HB PINK - Agency BLUE - Employee
)
Year

C
Member Account Management Division
P.O. Box 942715
Sacramento, CA 94229 -2715
(888) CalPERS (or 888-225-7377)
TTY (877) 249-7442
FAX (800) 959-6545
Declaration of Health Coverage: HBD-12A
EMPLOYEE INFORMATION
SOCIAL SECURITY NUMBER
NAME (FIRST)
(INSTRUCTIONS ON REVERSE)
(MIDDLE)
(LAST)
-
-
PART A
I elect to enroll myself and all eligible
dependents.
PART B-1
I elect to enroll myself. My eligible
dependents have other health
insurance coverage.
If you or your dependents lose health insurance
coverage, you can enroll in the CalPERS Health Benefits
Program. You must request enrollment within 60 days
from the date you lose coverage.
PART B-2
I elect to enroll myself and all eligible
dependents. I also have eligible
dependents who have other health
insurance coverage.
PART C-1
I decline enrollment for myself and
my eligible dependents because we
have other health insurance coverage.
PART C-2
I decline enrollment for myself and/or
my eligible family members for
reasons other than having health
insurance coverage.
If you do not request enrollment within 60 days, you or
your dependents must wait at least 90 days or until the
next Open Enrollment Period before you can enroll in
the Program. Your effective date of coverage will be
the first of the month following the 90-day waiting
period or the Open Enrollment effective date.
You can request enrollment for yourself and/or your
dependents at any time. You must wait at least 90 days
after you request enrollment or until the next Open
Enrollment Period before you can enroll in the Program.
Your effective date of coverage will be the first of the
month following the 90 day waiting period or the Open
Enrollment effective date.
PART B: If you are currently enrolled in the Health Benefits Program and you acquire new dependents
or if a court orders health coverage for your dependents, you can add your new dependents. See your
Health Benefits Officer or visit your personnel office for applicable time limits.
PART C: If you are not currently enrolled in the Health Benefits Program and you acquire new
dependents as a result of marriage, birth, adoption, or placement for adoption, or if a court orders health
coverage for your dependents, you can enroll yourself and dependents. See your Health Benefits Officer
or visit your personnel office for applicable time limits.
Special rules apply to retirement and death. Please read the back of this form carefully.
Member’s Signature
Date Signed
Health Benefits Officer’s Signature
Rev 12/15 Original: Employee’s Personnel File Copy: Employee
INSTRUCTIONS – DECLARATION OF HEALTH COVERAGE (HBD-12A)
Please contact your Health Benefits Officer if you have any questions regarding the HBD‐12A.
Employee Complete with the appropriate employee information.
Information
Part A:
Mark this box if you are:
a) Enrolling in the Health Benefits Program and have no dependents, or
b) Enrolling yourself and ALL eligible dependents in the Health Benefits Program.
Part B-1:
Mark this box if you are:
a) Enrolling yourself only, your dependents have other health insurance coverage, or
b) Canceling your dependents’ coverage because they have other health insurance
coverage
Part B-2:
Mark this box if you are:
a ) Enrolling yourself and SOME of your dependents, your other dependents have health
insurance coverage, or
b) Canceling coverage for some of your dependents because they have other health
insurance coverage.
Part C-1:
Mark this box if you are:
a) Declining enrollment or canceling your health insurance coverage, you have no
dependents and you have other health coverage, or
b) Declining enrollment or canceling your health insurance coverage for yourself and
eligible dependents and you have other health insurance coverage.
Part C-2:
Mark this box if you are:
a) Declining enrollment or canceling your health insurance for reasons other than
having health insurance coverage and you have no dependents, or
b) Declining enrollment or canceling your health insurance coverage for yourself and
eligible dependents for reasons other than having health insurance coverage.
IMPORTANT: It is your responsibility to notify your personnel office when there are any changes in
your family situation. Changes include marriage, acquisition of a dependent child, divorce, legal
separation, and death. Failure to notify your personnel office may result in adverse consequences.
Special rules to consider for retirement and death:
Retirees: you are eligible to enroll in a CalPERS health plan if you meet all of the criteria below:




Your retirement date is within 120 days of separation from employment
You are eligible for health benefits upon separation
You receive a monthly retirement allowance
You retire from the State, California State University (CSU), or an agency that currently contracts with
CalPERS for health benefits
Survivor Death Benefit: your dependents may enroll in a CalPERS health plan as a survivor as long as they:
 Are eligible for enrollment as a dependent on the date of death of a CalPERS retiree
 Receive a monthly survivor check
 Continue to qualify as an eligible family member
Dependents who are enrolled at the time of the employee or annuitant’s death and meet the eligibility
requirements can continue the health enrollment as a survivor. Dependents who are not enrolled and meet
the eligibility requirements may enroll in a health plan within 60 days of the employee or annuitant’s death, or
during Open Enrollment.
The effective date of enrollment is the first day of the month following the date CalPERS receives the
request. Exceptions may apply for certain contracting agency survivors who do not receive a monthly
survivor check. Your survivor will need to contact your former employer for additional information.
Privacy Notice
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.
Information Purpose
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
CalPERS being unable to perform its functions
regarding your status.
Please do not include information that is
not requested.
Social Security Numbers
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
Social Security number 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 purposes:
1. Enrollee identification
2. Payroll deduction/state contributions
3. Billing of contracting agencies for employee/
employer contributions
4. Reports to CalPERS and other state agencies
5. Coordination of benefits among carriers
6. Resolving member appeals, complaints,
or grievances with health plan carriers
Information Disclosure
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 confidentiality.
Your Rights
You have the right to review your membership
files maintained by the System. For questions
about this notice, our Privacy Policy, or your rights,
please write to the CalPERS Privacy Officer at
400 Q Street, Sacramento, CA 95811 or call us
at 888 CalPERS (or 888-225-7377).
May 2016