Forms & Documents

• Change of Address/ contact information 

Active Participants

• Platinum Plus
• Enrollment Form Instructions for Platinum Plus
• Platinum
• Enrollment Form Instructions for Platinum Plan
• Silver Clerks Less Than Two Years and Courtesy Clerks
• Silver/Gold

Retirees

• Enrollment Form for Retirees
• Enrollment Form Instructions
• Retiree Premium Authorization
• Drug Fund Retiree Premium Authorization

• Application for Coverage of Child as Dependent Pending Adoption
• Application for Coverage of a Foster Child
• Eligibility for Disabled Dependent Children
• Student Certification

• Appeal Form
• Claims & Appeals Procedures Booklet
• Appointment of Authorized Representative for Appeal

• Affidavit of Current Marital Status
• Application for Reinstatement of Eligibility for Leave or Hours Reduction Related to COVID-19
• Working Spouse Affidavit
• Silver Spouse/Domestic Partner Eligibility for Health Care Coverage
• Application for Reinstatement of Eligibility
• Beneficiary Designation (Death Benefit)
• HRA Rx Option
• Notice of Creditable Coverage Part D To All Participants Except E Retirees
• Notice of Creditable Coverage Part D To All Participants Except E Retirees (2022)
• Notice of Creditable Coverage for Plan E Retirees who are members of Kaiser Senior Advantage
• Notice of Creditable Coverage for Plan E Retirees who are members of Kaiser Senior Advantage (2022)
• Notice of Non-Creditable Coverage for Plan E Retirees who are enrolled in the Indemnity PPO Medical Plan or UHC Medicare
• Notice of Non-Creditable Coverage for Plan E Retirees who are enrolled in the Indemnity PPO Medical Plan or UHC Medicare (2022)

• PHI Forms
  • Appointment of Authorized Representative
  • Notification of HIPAA Personal Representative 
  • PHI Authorization 
• Plan A Platinum Benefit Highlights
• Plan B Platinum Benefit Highlights 
• Plan A & B Silver and Gold Benefit Highlights
• Registration Form for New Hires
• Schedule of Contributions to Premium
• Transferred Eligibility

• Cobra Coverage Election Form Platinum-Platinum Plus
• COBRA Continuation Coverage Important Information – Platinum Plus / Platinum Participants
• COBRA Election Form for Silver and Gold
• COBRA Continuation Coverage Important Information for Silver and Gold Participants
• COBRA Election Form for Retiree