Get Hbd 12

The Hbd 12 form is essential for active members who wish to enroll in health benefits. Completing this form correctly ensures that your enrollment process goes smoothly and effectively.

Follow the steps to complete the Hbd 12 form online.

1. Press the ‘Get Form’ button to access the Hbd 12 form and open it in your online editor.
2. Fill out Boxes 1, 2, 3, 4A, 4B, 5, 6, 7, 8, 9, 10, 11, 12, 13, 17, 18, 19, 20, and 21 as an active member, ensuring accuracy in every detail.
3. Input your Social Security Number in Boxes 2 and 3, along with your spouse or domestic partner's SSN if applicable. If unavailable, provide them as soon as possible.
4. In Box 4A, enter your full name as it appears on official documents, and in Box 4B, include your residence ZIP code.
5. Complete Boxes 5, 6, and 7 by indicating your employment status and marital status as required.
6. For Boxes 8 and 9, refer to the Health Program Guide to input the correct plan code and health plan name.
7. In Box 10, note the gross premium using the appropriate rate sheet for current health plan rates.
8. Fill out Box 11 with the name of your primary care physician or medical group associated with your HMO selection.
9. If applicable, enter the prior plan code and health plan details in Boxes 12 and 13, especially if changing or canceling coverage.
10. Complete the employer sections, Boxes 14 to 35, if required, following specific instructions for each field.
11. Once all information is accurately filled in, save your changes, and download or print the completed form for your records.
12. Share or submit the Hbd 12 form as required by your employer, ensuring that you retain a copy for personal tracking.

Start completing your Hbd 12 form online today to ensure your health benefits enrollment is processed without delay.