Active:
- Universal Enrollment Form (for changes/additions/deletions of ALL dependents)
- Universal Enrollment Form (Active, Eligible Retirees)
- Universal Enrollment Form (for PTF w/o REP and TEA for 6 months plus 1 day employment status)
- Universal Enrollment Form (PTF)
- CalPERS Health Plan Enrollment for Employees - Form HBD-12 (ALSO needed for changes/additions/deletions of ALL dependents)
- when enrolling/adding a Spouse or Domestic Partner:
- CalPERS Affidavit of Marriage and Domestic Partnership - Form PERS HBSD-1965 (To be used in lieu of Marriage Certificate; Domestic Partners Must Complete)
- when enrolling/adding a Child:
- CalPERS Affidavit of Parent-Child Relationship - Form HBD-40 (To be used in lieu of Birth Certificate; Passport accepted)
- CalPERS Disabled Dependent Questionnaire - Form HBD-98 (if applicable)
- CalPERS Disabled Dependent Medical Certification - Form HBD-34 (if applicable)
Retiree:
- CalPERS Health Benefits Enrollment Form
- CalPERS Certification of Medicare Status
- Retiree Change of Address Form
- Electronic Fund Transfer (EFT) Information
- Electronic Fund Transfer (EFT) Authorization - administrated by Discovery Benefits (To be used by Eligible retirees, Retired Board of Trustees and Surviving Spouse only)
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
- Transition Steps for Non-Pay status Benefits Eligible Part-time Faculty
Change of Address:
Medical Claim Form:
Prescription Drugs (RX):
- OptumRX Mail Order Service
- OptumRx Claim Form
- OptumRx Prescription Reimbursement Request Form
- OptumRX Prior Authorization Request Form
Dental:
Group Term Life Insurance:
- Hartford Insurance Death Claim form
- Hartford Beneficiary Designation Form
- Hartford Life Portability Application Form
- Hartford Notice of Conversion Form
Supplemental Term Life Insurance:
- Supplemental Life and AD&D Application-Personal Health Form *
- Hartford Beneficiary Designation Form *
- Hartford Insurance Death Claim form
*NOTE: these forms are mandatory
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:
- Hartford Buy-Up Long Term Disability Enrollment Form (LTD)
- Hartford Buy-Up Long-Term Disability Claim Form
- Hartford Buy-Up Long-Term Disability Insurance Insurance Premium Rates and Payroll Authorization Form
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.