Get Psers Health Options Program Application

Filling out the PSERS Health Options Program application online can seem daunting, but this guide will provide you with clear, step-by-step instructions to assist you in completing the process smoothly. Ensuring accurate and thorough information will help facilitate your enrollment in the program.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by entering the retiree information section. Include the retiree's name as it appears on their Medicare card, marital status, permanent address, and contact details. It is important to provide accurate information to prevent delays.
3. If you are enrolling dependents, complete the dependent information section. Provide each dependent's name, birth date, relationship to the retiree, and Medicare information, if applicable. Ensure you attach a copy of the Medicare card for each dependent.
4. In the option selection section, check all boxes for the medical, prescription drug, and dental coverage options you wish to enroll in. If retaining current coverage, do not complete this section.
5. Specify the date(s) you want coverage or changes to begin for both retiree and dependent. Remember that enrollment must occur within 180 days of a qualifying event.
6. Carefully answer the questions provided regarding any existing medical or prescription drug coverage, and indicate if any special assistance services are needed.
7. Read thoroughly through the important information sections provided, as they outline the terms and conditions of the application and program.
8. Finally, sign and date the application where indicated. If applicable, ensure an authorized representative also signs the form. Include the first month’s premium payment if submitting less than six weeks prior to your desired effective date.
9. After completing the form, review all entries for accuracy before saving changes. You may download, print, or share the completed application as necessary.

Start completing your PSERS Health Options Program application online today.