Human ResourcesForms



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):


Group Term Life Insurance:

Supplemental Term Life Insurance:

Flexible Spending Accounts (FSA Medical), Dependent Care (DCA), & Transportation Spending Account(TSA)

Important Deadline for FSA claims submission:

Deadline to apply for FSA reimbursement of expenses incurred for the Plan Year 2019 (January – December) with WageWorks: March 31, 2020. For PY 2020, the deadline is March 31, 2021 with Discovery Benefits.

Discovery Benefits replaces WageWorks as the new Third-Party Administrator effective January 1st, 2020.

*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:


  • Universal Enrollment Form

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