Get Retired Pennsylvania State Police Program - Annuitant Change Form (pebtf-18). Annuitant Change Form

Filling out the Retired Pennsylvania State Police Program - Annuitant Change Form (PEBTF-18) is a crucial step for managing your health benefits effectively. This guide will provide you with detailed instructions to ensure a smooth completion of the form.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access and open the form in an editor.
2. Begin by filling out the Annuitant Demographics section. Provide your title (Mr., Mrs., Ms., Dr.), your full name (Last, First, Middle initial), home telephone number, street address, alternate telephone number, city, state, zip code, and county name.
3. Indicate any changes you wish to make to your health benefits record by checking the appropriate boxes. Options include changing your address, removing or adding dependents, dis-enrolling or re-enrolling, changing medical plans, or listing other reasons.
4. If applicable, provide the effective date for the changes being requested.
5. In the Annuitant / Dependent Enrollment Data section, fill in the relationship of each dependent and their details, including full name, social security number, Medicare number and dates, and choose the appropriate medical or Medicare plan options.
6. Complete the section regarding your spouse's other health coverage if relevant, and provide their social security number if they have other coverage.
7. Fill out the List Other Medical Coverage For Enrollees section with the insured's name, ID number, employer group, group number, and the names of other people on the policy.
8. Read the authorization statement carefully before signing and dating the form. This section outlines your agreement to the terms related to enrollment and benefit payments.
9. After completing the form, save any changes made and prepare to print or share the completed document as needed.

Complete your Retired Pennsylvania State Police Program - Annuitant Change Form online today for seamless processing.