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Active:

Retiree:

Direct Pay:

  • CalPERS Direct Payment Authorization(form PERS-HBD-21)This form is required for: a) non-qualified retirees of FHDA to enroll into a medical plan directly with CalPERS, b) individuals who become "self-paying", due to a leave of absence, or other authorizations related directly to CalPERS.

Change of Address:

Medical Claim Form:

Prescription Drugs (RX):

Dental:

Group Term Life Insurance:

Supplemental Term Life Insurance:

Flexible Spending Accounts (FSA), Health Care (HCA), & Dependent Care (DCA)

Important Deadline for FSA claims submission:

Deadline to apply for FSA reimbursement of expenses incurred for the Plan Year 2016 (January – December): March 31, 2017. For PY 2017, the deadline is March 31, 2018.

*Terminated employees must submit FSA claim form within 90 days from the last day of active coverage.

Workers Compensation:

To be completed by the injured worker(The worker may be assisted by health services):

To be completed by the injured worker's supervisor:

Long-Term Disability:

C.O.B.R.A.:

  • Universal Enrollment Form

    You must complete the Universal Enrollment Form AND the appropriate form below to enroll into C.O.B.R.A.