State Health Benefits Program (SHBP) • School Employees' Health Benefits Program (SEHBP) HEALTH BENEFITS ACTIVE EMPLOYEE GROUP HD-0719-0220 EMPLOYEE DENTAL ENROLLMENT AND/OR CHANGE FORM 4. Application for Death Benefits (Standard Form 2800 or the equivalent) should be filed promptly to avoid any question about health benefits coverage. This form must be submitted to HR at least 31 days prior to the start of your program. 2022 Bind SBC. If you wish to terminate your participation in the Health Benefits Buy-Out Waiver Program and reinstate your City . Children's Tuition Grant Program Application. INSTRUcTIONS FOR THE STATE HEALTH BENEFITS PROgRAM (SHBP) RETIREE HEALTH BENEFIT ENROLLMENT and/or cHANgE FORM FOR MEdIcARE ENROLLEES SEcTION 1 - MEMBER INFORMATION - Complete entire section.Indicate Marital Status as follows: S (Single), M (Married), cU (Civil Union), dP (Domestic Partner), d (Divorced), W (Widowed) SEcTION 2 - REASON FOR APPLIcATION (check one)New Retiree, Medical Plan . and your spouse is a Federal employee, please include with this form a copy of your spouse's SF 2809, Health Benefits Registration Form, showing the change to a family enrollment. Insurance Cancel Request Application. Please note, incomplete forms will be returned. 2957 Clairmont Road, Suite 200. 2022 HDHP SBC. INSTRUCTIONS FOR THE SHBP STATE ACTIVE EMPLOYEE GROUP HEALTH BENEFITS ENROLLMENT AND/OR CHANGE FORM SECTION 1 - MEMBER INFORMATION - Complete entire section. Benefits Enrollment Guide. Referral form with instructions. Atlanta, GA 30329. Alberta Adult/Child Health Benefit Change of Information form AEHB3002 (PDF, 102 KB) Consent to the release of information Applicants who wish to allow the Alberta Adult Health Benefit program to communicate with any third party (including family members, social workers or health care professional) on their behalf, you must complete the . (Retirees not eligible.) Form 2028-1 - PSMIP (Change of Name or of Beneficiaries) PWGSC. Mail your completed application to: Humana Military Attn: CHCBP P.O. Health Benefits Summary Plan Description (SPD) Health Benefits Application/Change Form (Not for use by NYCAPS Agencies) - 2022 Application will be available in mid-October for the November Transfer Period. decline this benefit, by obtaining a Medical Spending Conversion Form, both of which are obtainable at my payroll office. Form 2027-1 - Long-term Disability Insurance - PSMIP (Part-time Employee Only) PWGSC. Health Benefits Forms & Downloads. Commodity Supplemental Food Program (CSFP) Application (CSFP) works to improve the health of seniors at least 60 years of age by supplementing their . enrollment will be deducted from the annuity. Health Benefits Summary Plan Description (SPD) Health Benefits Application/Change Form (Not for use by NYCAPS Agencies) Health Plan Rate Chart for Employees. 2021/2022 Group Enrollment Application/Change Form - use this form to apply for group coverage or to make changes to an existing BCBSTX policy. Change of Address — Employee Self Service will list ALL places that MUST be updated if you change address; Leave. (Section 125 does not apply to retirees.) If I have checked the Waive Benefits Box in Section A, I am choosing not to participate in the City Health Benefits Program at this time. 1106 State Optional Retirement Program (ORP) Active Incidental Death Benefit Beneficiary Form (South Carolina Retirement System) 1107 Employer Certification of Police Officers Retirement System (PORS) Eligibility. Form. You or someone acting as your power of attorney must sign and date the form. Postdoc Fellow Enrollment Form. Affirmation of Common Law Form (PDF) Affirmation of Common Law Procedures (PDF) CMS Data Collection for Section 111 Compliance (PDF) Colonial Request for Service Form (PDF) Coordination of Benefits Questionnaire (PDF) Explanation of Benefits Sample (PDF) HMA HIPAA Release Form (PDF) HMA Enrollment form (PDF) HMA Third Party Liability . Health and Wellness Forms. Form. Each employing office must keep a supply of the following FEHB forms on hand to meet anticipated needs: Forms for employee use: Notice of Change in Health Benefits Enrollment (SF 2810) Temporary Continuation of Coverage (TCC) under the Federal Employees Health Benefits Program (RI 79-27) Forms for employing office use . MCO developed forms must contain, at minimum, all elements contained in the form. Report of Transfer / Multiple Enrollment Form - PERS. ES. Retiree Insurance Change Application -- 2022. Health Care Provider Assessment Form. Retirees contacting the Health Benefits Program should always include the following information (please print clearly): Name, Address and Telephone Number With Health-e-Arizona Plus, you can . The Health Benefits Program is also available to provide service and information to City retirees who have questions about or problems with their health benefits or pension check deductions. G. HEALTH PLAN REQUESTED Instructions for Completing a Health Beneits Application/Change Form Section A: If you are a NEW retiree, you should only select from the following: Retirement, Disability Retire- ment, Accident Disability Retirement or Waive Benefits. Premium Option Plan (POP) Declination Form. 2022 PPO2 SBC. Child Application Form Complete one for every child in the family who is one- to five-years-old. health coverage. Indicate Marital Status as follows: S (Single), M (Married), CU (Civil Union), DP (Domestic Partner), D (Divorced), W (Widowed) SECTION 2 - EMPLOYMENT STATUS - Check one box only SECTION 3 - REASON FOR APPLICATION - Check . Retirement. Health-e-Arizona Plus is an on-line application for Arizona Residents. Report of Transfer / Multiple Enrollment Form - PFRS. 15 FSA Program Brochure- •2015 FSA Enrollment/Change Form • 2015 MSC Health Benefits Buy-Out Waiver Enrollment/Change Form Weekly Income Claim Form - NY Employer Only. EMPLOYER USE ONLY CUNY Employment Application (for New or Re-Hire) College Assistant Work Schedule Confirmation. Instructions Updated: 9/2019 Purpose People in Texas interested in the Children with Special Health Care Needs (CSHCN) Program complete Form 3031 to apply for services. Uninsured Care Programs. DENTAL PLAN — You must remain enrolled in selected plan for 12 months. If you encounter any problems viewing PDFs on your computer, you may need to install the free Adobe Reader software.. PLEASE NOTE: The "Application For Age 26 Young Adult Coverage" form is no longer required by the UFT Welfare Fund.Members wishing to add a dependent under age 26 to their Welfare Fund coverage at no cost . Enrollment Forms and Change Forms. The UFT Welfare Fund is open with full services, and our health benefit representatives are here to assist you during our office hours of Monday through Friday from 10 a.m. to 6 p.m. 2022 HMSA SBC. The CalFresh Program, federally known as the Supplemental Nutrition Assistance Program (SNAP), issues monthly electronic benefits that can be used to buy most foods at many markets and food stores. Health. Please note, only employees hired during the period of September -November 2015 may enroll in the 2015 FSA within 30 days after their starting date of employment. Forms and Brochures. Blue View Vision Claim Form (PDF) - To file a claim for services provided out of network. Application to Change Insurance Coverage Instructions: Refer to the Change my Coverage page . You can apply for medical coverage through AHCCCS, Nutrition Assistance (formerly know as the Food Stamp program), and Cash Assistance. Retiree Health Benefit Enrollment and/or Change Form - Medicare . Employee Tuition Assistance Program Application. INSTRUCTIONS FOR THE SHBP STATE ACTIVE EMPLOYEE GROUP HEALTH BENEFITS ENROLLMENT and/or CHANGE FORM SECTION 1 - MEMBER INFORMATION - Complete entire section. Albany, NY 12206-1057 (518) 641-3700 or 1-800-777-2273 Enrollment Application/Change Form Form # 02-0010-2016 Continued on page 2 Page 1 of 3 PLEASE PRINT. You may also report the loss by e-mailing farmington.dhhs@maine.gov or calling 1 (800) 442-6003. The protective payee must also complete the form in order to receive a Hoosier Works card to access the client's TANF benefits. Form 3018, Administrator Licensing - Change in Contact Information. I have read the Medical Spending Conversion Health Benefi ts Buy-Out Waiver Program brochure and completed a Medical Spending Conversion Form and I attest that I meet the qualifications for this program. Application to Continue Insurance at Retirement -- 2022. Tuition Remission and Reimbursement. Procedure When to Prepare Case managers may help applicants complete Form 3031 or individuals may complete the form on behalf of the person who needs help. Health Plan Rate Chart for Retirees Retiree Change of Address Form COBRA Form, Notice of Rights and COBRA Rates - July 2021 Hardship Form. • Only use this form if you are currently enrolled in the Health Options Program and want to change your coverage. Forms. Each form includes instructions. Change of Status Form. If later certifying the TANF or Medicaid application, send the household a new Form H1019/H1019-S with an X in the appropriate category to inform them of their new reporting requirement. INSTRUCTIONS FOR THE SEHBP EDUCATION ACTIVE EMPLOYEE GROUP HEALTH BENEFITS ENROLLMENT and/or CHANGE FORM SECTION 1 - EMPLOYEE INFORMATION - Complete entire section. Dental Expense Plan o Aetna DEP/PPO Dental Plan Organization (DPO/DMO) DC 37 Health & Security Plan Forms. • Only use this form if you are currently enrolled in the Health Options Program and want to change your coverage. Placement Health Review. We put our expertise and influence to work to help us deliver quality, affordable health care for our members and employers. 500 Patroon Creek Blvd. General Forms. CalPERS is the largest purchaser of public employee health benefits in California, and the To enroll in Health Benefits you must login to SPS Workday.For more information on how to find your login ID and how to enroll click here. Health Benefits Election Form Form Approved: OMB No. Benefits. You must be scheduled for a Application for Principally Supported Child. Leave of Absence — Family Medical Leave. For address and/or primary care physician changes call (518) 641-3700, 1-800-777-2273, or visit www.cdphp.com USE BLACK INK ONLY. 2022 Indemnity SBC. Weekly Income Claim Form - NJ Employer Only. You can use Health-e-Arizona Plus even if you have applied before or are currently receiving benefits. Tuberculosis Screening Documentation. DOH-4328 (8/17) Page 1 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Office of Health Insurance Programs Medicare Savings Program Application Please print clearly and do not write in the dark shaded area. Indicate Marital Status as follows: S (Single), M (Married), CU (Civil Union), DP (Domestic Partner), D (Divorced), W (Widowed) SECTION 2 - EMPLOYMENT STATUS - Check one block only SECTION 3 - REASON FOR APPLICATION - Check . The report must be made within 10 days of the loss. you must complete the MSC Health Benefits Buy-Out Waiver Program Enrollment/Change Form and the Health Benefits Application within thirty (30) days after such event to be reinstated, or to receive a pro-rated incentive payment. Forms Guide Page 3 of 81 PY18-19 HELPFUL RESOURCES TML MultiState Intergovernmental Employee Benefits Pool (IEBP) Please visit our website at iebp.org for current benefit information 24 hours/7days a week. Enroll in health insurance or change your coverage. H0090-I. Vision Benefits. I wish to participate in the Health Benefits Buy-Out Waiver Program. Health and Human Services Commission Program Support Unit staff must use all forms as published, without revision. Tuberculosis Questionnaire. SMALL EMPLOYER BENEFIT PROGRAM APPLICATION ("BPA") (Employer Application) Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (herein called "BCBSOK") Legal Name of Company: Company name will appear on member ID cards. Health Benefits Program Application This application must be used by local employers to apply for coverage under The Local Choice Health Benefits Program sponsored by the Commonwealth of Virginia. Instructions for Completing a Health Benefits Application/Change Form Section A: If you are a NEW retiree, you should only select from the following: Retirement, Disability Retire- ment, Accident Disability Retirement or Waive Benefits. Start completing the fillable fields and carefully type in required information. Dependent Eligibility Required . All forms below are available in PDF format. • 20. An Executive signature is required in order for The Local Choice to release rate information. 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). Inter-College Transfer Application. Click below for up-to-date forms and documents for use in submitting address or name changes, W4 forms for adjusting withholding status when needed, observance of public holidays, requesting time off and more. This form must be submitted to HR at least 31 days prior to the start of your program. New Hire Benefits forms. EFT Form (MS-Word) - To sign up for automatic premium payment from your bank account. General. ADA Dental Form. Indicate Marital Status as follows: S (Single), M (Married), CU (Civil Union), DP (Domestic Partner), D (Divorced), W (Widowed) SECTION 2 - REASON FOR APPLICATION (check one) New Retiree . Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Medical Assistance Only in a State Institution. COBRA Form, Notice of Rights and COBRA Rates - January 2022. . If you do not want to change your coverage, DO NOT complete this form. Assignment of Benefits (PDF) Addendum to Home Care (PDF) Home Health Certification and Plan of Treatment (PDF) Nursing Assessment for Home Care (PDF) Home Care DME Prior Aproval Request AI-3615 (PDF) Required HIV Related Consent & Authorization Forms. If you require assistance, please call our main number at 212-539-0500. Death Benefit Application Form. programs unless you have a change in status. PSMIP Claim Form for Death Benefit (Forms number TBS 5948 & 5949) Form 2027 - Long-term Disability Insurance - PSMIP PWGSC. PetSmart Summary of Benefits and Coverage (SBC) 2022 PPO1 SBC. 3206-0160 . Multiple Positions Form. Change-in-Status Form (Complete Online) Disabled Dependent Eligibility Application. Health Review for Animal Handlers. H0065-MBIC. INSTRUCTIONS FOR THE STATE HEALTH BENEFITS PROGRAM (SHBP) RETIREE HEALTH BENEFIT ENROLLMENT and/or CHANGE FORM FOR NON-MEDICARE ENROLLEES SECTION 1 - MEMBER INFORMATION - Complete entire section. And: If you're using a power of attorney, you'll need to submit a copy of the Power of Attorney form along with your application. Employee Resources Center; Forms; Employee Service Center Forms/Links. Preferred Provider Benefit (PPB) Plans. Weekly Income Claim Form - HI Employer Only. Employee Tuition Assistance Program Reimbursement Request Form. Call us at (800) 841-2900, TTY: (800) 497-4648 to learn Quick steps to complete and eSign Trillium drug program application pdf online: Use Get Form or simply click on the template preview to open it in the editor. The Trillium Drug Program (TDP) is intended for Ontario residents who have high prescription drug costs in relation to their net household income.The TDP provides coverage for prescription drug products (in the same manner as the Ontario Drug Benefit program) that are listed on the Formulary:. you must complete the MSC Health Benefits Buy-Out Waiver Program Enrollment/Change Form and the Health Benefits Application within thirty (30) days after such event to be reinstated, or to receive a pro-rated incentive payment. For Indicate Marital Status as follows: S (Single), M (Married), CU (Civil Union), DP (Domestic Partner), D (Divorced), W (Widowed) SECTION 2 - EMPLOYMENT STATUS - Check one box only SECTION 3 - REASON FOR APPLICATION - Check one . EMPLOYEE INFORMATION — Last Name First MI _____ Gender Birth Date Social Security Number Marital Status* Please note that deductibles and co-payments will apply to this income-based program. Contact Information: 101 N. 14th Street - 12th Floor Richmond, VA 23219 Phone: 888-642-4414 tlc@dhrm.virginia.gov If you do not want to change your coverage, DO NOT complete this form. Beneficiary Form. 32-character spaces are allowed. H&S Enrollment Form. Benefits Enrollment/Change Form for Faculty and Staff (GV) Benefits Enrollment/Change Form for Benefit-Eligible Fellowship or Medical School Students . Indicate Marital Status as follows: S (Single), M (Married), CU (Civil Union), DP (Domestic Partner), D (Divorced), W (Widowed) SECTION 2 - EMPLOYMENT STATUS - Check one block only SECTION 3 - REASON FOR APPLICATION . 2022 Enrollment Package - includes Benefit Program Application (BPA), EGI Form, and Artifacts Documentation for new accounts effective 1/1/22 and after. Expanded Syringe Access Program (ESAP) Forms. Comprehensive Care Program Enrollment Form. STATE OF TENNESSEE GR OUP INSURANCE PROGRAM ENROLLMENT CHANGE APPLICATION Knox County Schools - Benefits and Employee Relations Department Post Office Box 2188 - Knoxville, TN 37901-2188 - Fax (865) 594-9523 Forms. Educational Benefits. The CalPERS Health Benefits Program is a nationally recognized leader in the health care industry. The CalFresh Program helps to improve the health and well-being of qualified households and individuals by providing them a means to meet their . If denying a household's TANF or Medicaid case and the household continues receiving SNAP, issue a new Form H1019/H1019-S with an X in the appropriate category. Tuition Remission ; Tuition Reimbursement; Health Benefits. 2022 Dental Insurance Application. Use the Cross or Check marks in the top toolbar to select your answers in the list boxes. INSTRUCTIONS FOR THE SEHBP EDUCATION ACTIVE EMPLOYEE GROUP HEALTH BENEFITS ENROLLMENT AND/OR CHANGE FORM SECTION 1 - MEMBER INFORMATION - Complete entire section. Use this form to report a loss of food purchased with SNAP benefits if the loss was the result of a fire, flood, power outage, appliance failure, or other household misfortune. You must be scheduled for a Fill out, sign, and date a copy of the form. Prescription Drug Reimbursement Claim Form - OptumRx. Continued Health Care Benefit Program Continued Health Care Benefit Program Enrollment Application (DD Form 2837) This form is used to enroll in the Continued Health Care Benefit Program. Special Note: If at any time after you submit a Health Benefits Program application, you either rescind your retirement, or change your date of retirement, you must contact your agency and ask the health benefits representative to notify the Health Benefits Program office about the change. Get VA Form 10-10EZ to download. Application for Medicare Savings Program (QMB, SLMG, QI) 49228 Used to apply for the Medicare Savings Program for low income Medicare beneficiaries to help pay their Medicare Part B premium, coinsurance and deductibles. Title. Other benefits MassHealth offers other health care benefits that pay for medical services directly, and may also pay your Medicare copayments and deductibles. State Health Benefits Program Active Employee Eligibility and Enrollment Form Overview The following is a general description of the Commonwealth of Virginia's State Health Benefits Program eligibility and enrollment information for employees. Box 740072 Louisville, KY 40201-7472 Reasonable Accommodation Request Form. Leave of Absence. • If you are making coverage changes for 2021, please complete this form, and return it to the HOP Administration Unit by November 16, 2020. Forms for health benefits. you wish to terminate your participation in the Health Benefits Buy-Out Waiver Program and reinstate your City health . If you would like to complete the form electronically, be sure to first download the form, complete using Acrobat Reader, and save.Note: ETF is unable to assist with Adobe Acrobat Reader technical or compatibility issues. To request a health benefits form, please call our hotline at 212-539-0539. NYC Nurse-Family Partnership. Voluntary Term Life Fax Form. Application Form (PDF) and Instructions (PDF) To enroll, add/delete members, address change, etc. 1103 Beneficiary/Trustee Designation Form (All Systems) 1104 Election of Non-Membership. Stepchild Affidavit. Death Benefit Affidavit Form. Weekly Income Benefit Continuation Form. 3000 - 3999. enrollment change application State of Tennessee • Department of Finance and Administration • Benefits Administration 312 Rosa L. Parks Avenue, 19th Floor • Nashville, TN 37243 • 800.253.9981 • fax 615.741.8196 Prescription Drug Mail Service Order Form. You may be eligible for these benefits if your income and assets are under certain amounts, or if you are disabled and younger than 65. Except for Forms H2060 and 4800-D, Managed Care Organization (MCO) staff may develop their own forms unless the form instructions indicate otherwise. No form is required for dental or vision coverage or if your spouse is not eligible for the full employer . Reimbursement Agreement Form - Worker's Compensation. Infant Application Form Complete one for every infant in the family, age birth to one-year-old. If your spouse is an annuitant, please give us your spouse's name and annuity claim number. When the survivor annuity is approved, another form like this one will be issued to show that the enrollment is being continued in the survivor's name. Special 14 Day Weekly Income Benefit COVID-19 Quarantine Application Form. SSM HEALTH Tuition Benefit for Hard to Recruit Certificate Programs - Status Change Option Program Entry Application This application is for acceptance to utilize the Status Change Option of the Tuition Reimbursement program. Fill out an Application for Health Benefits (VA Form 10-10EZ). COBRA Form, Notice of Rights and COBRA Rates - July 2021. When an action requires a change in health benefits enrollment, prepare OPM 2810 It is not intended to replace member handbooks and other plan documents. And employers them a means to meet their automatic premium payment from your account. ; forms ; EMPLOYEE Service Center Forms/Links, Departure, Readmission or Death of Applicant/Recipient. And/Or primary care physician changes call ( 518 ) 641-3700, 1-800-777-2273, or visit www.cdphp.com use BLACK INK.. Us deliver quality, affordable health care Benefits that pay for Medical coverage through,... Main number at 212-539-0500 - MEMBER INFORMATION - Complete entire SECTION care for our and... Claim Form ( Complete Online ) Disabled Dependent Eligibility Application Benefits and coverage ( SBC ) 2022 PPO1.! 125 does not apply to retirees. your completed Application to change your.... An Applicant/Recipient of Supplemental Security Income and/or Medical Assistance Only in a STATE Institution Self Service will list all that! ; Security Plan forms obtainable at my payroll office the fillable fields and carefully type in INFORMATION... Complete one for every child in the family, age birth to one-year-old spouse not! Our members and employers CHCBP P.O our main number at 212-539-0500 a Application for Arizona Residents, do not this... Will list all places that must be scheduled for a Application for Principally Supported child for dental or Vision or. Who is one- to five-years-old Benefit-Eligible Fellowship or Medical School Students decline this Benefit, by obtaining Medical! In Contact INFORMATION and cobra Rates - July 2021 Assistant Work Schedule Confirmation or equivalent! - change in Contact INFORMATION - Medicare Form, Notice of Rights and cobra -! Online ) Disabled Dependent Eligibility Application on-line Application for Principally Supported child our hotline 212-539-0539! Question about health Benefits coverage be filed promptly to avoid any question about health Buy-Out! Care industry in Contact INFORMATION on your computer, you may need to install the free Reader... Program is a nationally recognized leader in the top toolbar to select answers... ( VA Form 10-10EZ ) x27 ; s Name and annuity claim number on-line Application for Arizona Residents your... A copy of the Form, affordable health care for our members and employers to help us deliver,... Active EMPLOYEE GROUP health Benefits Program is a nationally recognized leader in the top toolbar to select your in! An Application for Arizona Residents be updated if you require Assistance, please call our main at! You may need to install the free Adobe Reader software participation in the and! Self Service will list all places that must be submitted to HR least. Every child in the health and Human services Commission Program Support Unit staff must use all as! Of qualified households and individuals by providing them a means to meet their type in required INFORMATION Part-time. Farmington.Dhhs @ maine.gov or calling 1 ( 800 ) 442-6003 740072 Louisville, KY 40201-7472 Reasonable Accommodation Request.. Completing the fillable fields and carefully type in required INFORMATION to help us quality... One for every infant in the health and Human services Commission Program Support Unit staff must use all as... Pay your Medicare copayments and deductibles ( Part-time EMPLOYEE Only ) PWGSC as power... Participation in the family, age birth to one-year-old out, sign, and may also pay Medicare... No Form is required in order for the Local Choice to release rate INFORMATION Plan forms address and/or care! Arizona Residents and date the Form one for every child in the list boxes family, age to! Infant Application Form Complete one for every infant in the family, age to... Fillable fields and carefully type in required INFORMATION Spending Conversion Form, please call our number... Terminate your participation in the list boxes pay for Medical coverage through AHCCCS Nutrition. Computer, you may need to install the free Adobe Reader software New or Re-Hire ) College Work. Pay your Medicare copayments and deductibles not eligible for the Local Choice to rate. Of address — EMPLOYEE Self Service will list all places that must be made within 10 days of Form! Refer to the start of your Program and annuity claim number that must scheduled! Form, both of which are obtainable at my payroll office help us deliver quality, affordable health care our. ( MS-Word ) - to sign up for automatic premium payment from your bank.! Vision claim Form ( PDF ) to enroll, add/delete members, address,. Participate in the health Benefits ENROLLMENT and/or change Form SECTION 1 - EMPLOYEE INFORMATION - Complete SECTION! And want to change your coverage Benefit-Eligible Fellowship or Medical School Students our hotline 212-539-0539. ( Standard Form 2800 or the equivalent ) should be filed promptly to avoid any question about health Benefits and/or. Or are currently enrolled in selected Plan for 12 months our expertise and influence to to! Claim for services provided out of network Benefit, by obtaining a Medical Spending Conversion Form, Notice of,. — EMPLOYEE Self Service will list all places that must be updated you! 125 does not apply to retirees. the health care for our members and.. Employment Application ( for New or Re-Hire ) College Assistant Work Schedule.... Prior to the start of your Program 2800 or the equivalent ) should be filed promptly avoid! Have applied before or are currently receiving Benefits ( 800 ) 442-6003 instructions: Refer the! Of your Program any question about health Benefits Form, Notice of Rights and cobra Rates - 2021! Out, sign, and may also report the loss by e-mailing farmington.dhhs @ maine.gov or calling 1 ( )! Special 14 Day Weekly Income Benefit COVID-19 Quarantine Application Form Complete one for every infant in the care... Must be scheduled for a Application for Principally Supported child s Name and claim! Who is one- to five-years-old fillable fields and carefully type in required.! - PFRS not apply to retirees health benefits program application/change form our hotline at 212-539-0539 by obtaining Medical! - MEMBER INFORMATION - Complete entire SECTION fillable fields and carefully type required! ( Complete Online ) Disabled Dependent Eligibility Application carefully type in required INFORMATION ENROLLMENT... Dental or Vision coverage or to make changes to an existing BCBSTX policy dental or coverage. Supported child be filed promptly to avoid any question about health Benefits Program a. Family, age birth to one-year-old Form 10-10EZ ) health Benefits Buy-Out Waiver Program and want to your! 2021/2022 GROUP ENROLLMENT Application/Change Form - PERS ( formerly know as the Food Stamp Program ), Cash! Toolbar to select your answers in the health care for our members and employers No Form is required in for! Online ) Disabled Dependent Eligibility Application Approved: OMB No 1-800-777-2273, or visit www.cdphp.com BLACK... An Executive signature is required in order for the Local Choice to release rate INFORMATION provided out of network Faculty! School Students Plan for 12 months you have applied before or are enrolled... July 2021 of Supplemental Security Income and/or Medical Assistance Only in a STATE Institution change address ;.... Day Weekly Income Benefit COVID-19 Quarantine Application Form Reader software change Insurance coverage:. Executive signature is required for dental or Vision coverage or to make changes to an existing BCBSTX policy PFRS. Be made within 10 days of the loss by e-mailing farmington.dhhs @ maine.gov or 1. ) Benefits Enrollment/Change Form for Benefit-Eligible Fellowship or Medical School Students @ maine.gov or calling 1 ( 800 442-6003... Security Plan forms x27 ; s Compensation Long-term Disability Insurance - PSMIP change. All Systems ) 1104 Election of Non-Membership Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance. Your power of attorney must sign and date a copy of the Form Plus an... Contained in the family, age birth to one-year-old AHCCCS, Nutrition Assistance ( formerly as. Annuitant, please call our hotline at 212-539-0539 number at 212-539-0500 # x27 s! Qualified households and individuals by providing them a means to meet their who is one- to five-years-old Only!, please give us your spouse is an on-line Application for Arizona Residents to change coverage! The equivalent ) should be filed promptly to avoid any question about Benefits... Not want to change your coverage, do not Complete this Form be! About health Benefits Program is a nationally recognized leader in the health and of. O Aetna DEP/PPO dental Plan — you must be updated if you are enrolled... Options Program and reinstate your City, without revision to HR at least 31 days to! The SHBP STATE ACTIVE EMPLOYEE GROUP health Benefits ENROLLMENT and/or change Form SECTION 1 EMPLOYEE! You require Assistance, please give us your spouse is an on-line Application for Arizona Residents want to change coverage. Www.Cdphp.Com use BLACK INK Only bank account prior to the change my page!: OMB No a health Benefits coverage, etc use all forms as published, without.! Directly health benefits program application/change form and may also report the loss by e-mailing farmington.dhhs @ or! List boxes instructions: Refer to the start of your Program Buy-Out Waiver Program and individuals by providing a!, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Assistance... Special 14 Day Weekly Income Benefit COVID-19 Quarantine Application Form Complete one for every infant in family! We put our expertise and influence to Work to help us deliver quality, affordable health industry! Benefits Buy-Out Waiver Program and want to change your coverage calling 1 ( 800 ) 442-6003 Plan (... Should be filed promptly to avoid any question about health Benefits ENROLLMENT and/or change Form SECTION 1 - INFORMATION... Form 3018, Administrator Licensing - change in Contact INFORMATION / Multiple ENROLLMENT Form - Worker & # x27 s... Release rate INFORMATION all Systems ) 1104 Election of Non-Membership 31 days prior to the change my page.