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.
  • CalPERS Direct Pay Plan Guide
  • Effective 01/01/22, Adjunct Faculty members are no longer required to be transitioned to Direct Pay through CalPERS to continue their health benefits while under non pay status. Instead, we ask that the Faculty members mail us the payment to pay for their benefits in advance if they are not teaching for the quarter.

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 2023 (January – December) with WEX, Inc: March 31, 2024. 

Discovery Benefits rebranded as WEX, Inc effective February 26th, 2021.

*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.