Get Dc Health Care Enrollment Form (1269) - District Of Columbia ... - Dcrb Dc

Filling out the DC Health Care Enrollment Form (1269) is a vital step for individuals seeking health benefits in the District of Columbia. This guide will walk you through each section of the form, providing clear instructions to ensure you complete it accurately and efficiently.

Follow the steps to successfully complete the enrollment form.

1. Press the ‘Get Form’ button to acquire the DC Health Care Enrollment Form (1269) and open it for editing.
2. Begin filling out Part A by entering your full name, including last name, first name, and middle initial. Next, provide your date of birth using the numerical format of month, day, and year.
3. Complete your mailing address with the number and street, city, state, and zip code. This ensures that you receive any necessary correspondence regarding your health benefits.
4. Indicate your marital status by answering whether you are currently married or not. Provide your social security number as required.
5. In the section regarding your gender, mark the appropriate box to indicate whether you identify as male or female.
6. List your work phone number in the designated field to provide your employer with a point of contact.
7. Proceed to Part B where you will enroll in a health benefits plan. Select your plan type, either 'Self Only' or 'Self and Family,' and authorize salary deductions to cover your share of the enrollment costs.
8. In the space provided, list all eligible family members, starting with your spouse followed by your unmarried children, including their dates of birth. Ensure that you only include eligible members as specified in the form.
9. If you plan to change your enrollment, complete the present plan information and any additional changes in Part C. Be sure to include relevant dates of events that permit changes.
10. Read the terms in Part E thoroughly and confirm if you or your family members have other health insurance coverage. Sign and date the form in Part F, ensuring that all information is accurate.
11. After reviewing the completed form for accuracy, save your changes. You may then download, print, or share the form as needed.

Complete your DC Health Care Enrollment Form online today for timely access to your health benefits.