Get Hi-22 2020-2026

The HI-22 form is essential for individuals seeking to continue their health benefits upon retirement. This guide provides step-by-step instructions on completing the form accurately, ensuring that all necessary information is provided for efficient processing.

Follow the steps to complete the HI-22 online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your employee number, last name, first name, middle initial, and address including city, state, and zip code.
3. Fill in your social security number and date of birth. Indicate whether you are classified or certificated and select your sex.
4. Provide your retirement date and specify whether you are applying for service retirement or disability retirement.
5. In the health plans section, choose the plans you wish to enroll in at the time of retirement by checking the appropriate boxes.
6. If applicable, provide dependent information, ensuring that you include the social security number for each dependent. Attach additional pages if necessary.
7. Complete the Medicare information section, as it is mandatory if you or your spouse is 65 years or older. Include the participant's Medicare claim number and effective dates.
8. Select your retirement system by marking either the State Teachers Retirement System (STRS) or the Public Employees Retirement System (PERS).
9. Sign and date the form, confirming that all provided information is truthful and accurate.
10. Once completed, save your changes, download, print, or share the form as needed. Ensure you send it along with any required documents to the Benefits Administration.

Complete your HI-22 form online to secure your health benefits with ease.