Active:

• Universal Enrollment Form (Actives, Retirees; for changes/additions/deletions of ALL dependents)
• 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 WEX,Inc  (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
• 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:

• CalPERS Address Change Authorization Form

Medical Claim Form:

• Anthem Blue Cross Member Claim Form - Medical

Prescription Drugs (RX):

• OptumRX Mail Order Service
• OptumRx Claim Form
• OptumRx Prescription Reimbursement Request Form
• OptumRX Prior Authorization Request Form

Dental:

• Delta Dental Claim Form

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)

• Discovery Benefits FSA Enrollment Form, Currently this old form is still used by WEX, Inc

• WEX, Inc FSA Claim Form

Important Deadline for FSA claims submission:

Deadline to apply for FSA reimbursement of expenses incurred for the Plan Year 2022 (January – December) with WEX, Inc: March 31, 2023. 

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):

• DWC-1
• Workers' Comp Report of Injury Form
• State of California Employer's Report Form(Form 5020)

To be completed by the injured worker's supervisor:

• Supervisor's Claim and Safety Report

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

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.

• Active Employees
• Retirees