Follow the steps to successfully fill out the Non-State Reinstatement form online.

1. Click the ‘Get Form’ button to retrieve the Non-State Retiree Reinstatement Form and open it for editing.
2. Complete the Participant Information section with your accurate details, including your Social Security number, date of birth, and contact information. Ensure that this information is printed clearly.
3. In the Select Your Medicare Exchange Option section, choose whether you want dental coverage or not, and confirm your enrollment in either Via Benefits or TRICARE for Life.
4. Under Choose Coverage For, specify whether you are enrolling for yourself only or including a spouse or domestic partner. If applicable, ensure that both parties have Medicare A and B.
5. If adding an eligible spouse or domestic partner, complete the required fields, including their Social Security number and date of birth. Attach supporting documents such as marriage certificates or Medicare cards.
6. Carefully read the Authorization section and ensure you understand the implications of your selections. Provide your signature and the date on the appropriate line.
7. Once completed, review the form for accuracy and completeness. Any incomplete or incorrect forms will be returned.
8. Save your changes, then choose to download or print the form for submission. You can also share it via email if necessary.

Begin your process of reinstating your benefits by completing the NV Public Employees Benefits Program Non-State Reinstatement form online today.