Get Form 23: Health Election Change Form For The - State Of Oklahoma - Ok

The Form 23: Health Election Change Form is essential for individuals seeking to manage their health insurance deductions as retired public safety officers in Oklahoma. This guide provides step-by-step instructions to assist users in completing the form accurately and efficiently online.

Follow the steps to complete the Health Election Change Form online.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Begin by entering your name and Social Security number at the designated fields at the top of the form.
3. Indicate whether you are currently deducting insurance premiums from your pension check by marking 'Yes' or 'No'.
4. In Part I, choose the appropriate option for your benefit commencement: 'New Insurance Deduction', 'Change Insurance Deduction', or 'Terminate Insurance Deduction'. Specify the effective date for this change.
5. Move to Part II, where you will select your health insurance preference by checking either the accident or health insurance plan or a qualified long-term care insurance contract.
6. In Part III, provide the necessary payment instructions. This includes the name of the insured or contract holder, their account number, as well as the name and address of the insurance provider.
7. Complete the contact information for the insurance provider, including a contact name and telephone number, followed by the amount to be paid monthly.
8. In Part IV, read and understand the retiree's representations and understandings regarding the health insurance premiums. Although no additional action is required here, ensure you acknowledge these conditions.
9. In Part V, certify the accuracy of the information by signing and dating the form. Include your phone number for any necessary follow-up.
10. Once all sections of the form are completed, you can save changes, download, print, or share the form as required.

Complete and submit the Form 23 online to ensure your health insurance changes are processed promptly.