Get State Health Benefits Program Enrollment Form Fillinable

This guide provides step-by-step instructions for filling out the State Health Benefits Program Enrollment Form for retirees, survivors, and long-term disability participants. By following these instructions, users can efficiently complete the form online and ensure accurate enrollment in health benefits.

Follow the steps to successfully complete the online enrollment form.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. In Part A, fill in the enrollee's information, including their Social Security number, name, address, birth date, contact information, and indicate if this is an address change.
3. Select the reason for submitting the form by checking the appropriate categories, such as initial enrollment or open enrollment.
4. Indicate the type of membership by selecting the appropriate option (single coverage or family coverage).
5. In Part B, list all individuals being enrolled in the health plan, including their relationship to the enrollee, sex, birth date, and Social Security numbers.
6. Select the appropriate health benefits plan in Parts C and D, based on Medicare eligibility and dependent status. Ensure all family members are included under the same plan if not Medicare-eligible.
7. Complete Part E by signing the enrollee statement and certifying that all provided information is accurate. Ensure the form includes a signature of the enrollee and not of a dependent.
8. If canceling or waiving coverage, complete Part F with the required information and signature.
9. Review all sections for accuracy before finalizing. Users can then save their changes, download a copy for their records, print the form, or share it as necessary.

Complete your State Health Benefits Program Enrollment Form online today and ensure timely enrollment.