Follow the steps to successfully complete the form online.

1. Press the 'Get Form' button to obtain the form and access it in an online editor.
2. Begin with Section I, where you will provide your retiree information. This includes your name, employee ID number, last four digits of your Social Security number, address, home phone number, email, date of birth, and retirement date.
3. Move to Section II and select your reason for enrollment, ensuring you check one option such as 'Open Enrollment' or 'Transfer to active spouse MCPS plan'.
4. In Section III, indicate your desired level of health coverage by selecting from options like 'Individual', 'Two-Party', or 'Family'.
5. Proceed to Section IV, where you must make selections in categories A through D for medical plans, prescription drug plans, dental plans, and vision plans. Ensure you choose one option from each category.
6. In Section V, list any covered participants, such as your spouse or children, detailing their information for enrollment or dropping them as dependents.
7. Complete Section VI by indicating your choice regarding Basic Term Life Insurance and if applicable, whether you want to change your beneficiary.
8. Finally, in Section VII, designate primary and contingent beneficiaries by filling out their respective details. Remember to check the appropriate boxes.
9. Once all sections are filled, save your changes and ensure to electronically sign the form at the bottom of both pages.
10. After signing, you can download the completed form, print it, or share it as needed.

Complete your MD MCPS Form 455-22 online today for a streamlined enrollment process.