Health Benefit Plan Enrollment Form - California (Page 2 of 3) in pdf

PRIVACY INFORMATION

Submission of the requested information is mandatory. The information requested is collected

pursuant to the California Government Code (sections 20000 et seq.) and will be used for

administration of the Board’s duties under the Retirement Law, the Social Security Act, and the

Public Employees’ Medical and Hospital Care Act, as the case may be.

Portions of this

information may be transferred to another governmental agency (such as your employer) but only

in strict accordance with current statutes regarding confidentiality. Failure to supply the

information may result in the System being unable to perform its functions regarding your status.

You have the right to review your membership files maintained by the System. For questions

concerning your rights under the Information Practices Act of 1977, please contact the

Information Practices Act Coordinator, CalPERS, P.O. Box 942702, Sacramento, CA 94229-

2702.

Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or

local governmental agency which requests an individual to disclose his Social Security account

number shall inform that individual whether that disclosure is mandatory or voluntary, by which

statutory or other authority such number is solicited, and what uses will be made of it. Section

111 of Public Law 101-173 requires group health plans to collect and provide member Social

Security numbers for the coordination of federal and state benefits. Furthermore, Health Account

Services requires each enrollee’s Social Security number for identification purposes and to verify

eligibility for benefits. Specifically, the California Public Employees’ Retirement System uses

Social Security numbers for the following purposes:

1. Enrollee identification for eligibility processing and eligibility verification.

2. Payroll deduction and state contribution for state employees.

3. Billing of contracting agencies for employee and employer contributions.

4. Reports to the Public Employees’ Retirement System and other state agencies.

5. Coordination of benefits among carriers.

BINDING ARBITRATION

Enrollment in certain plans constitutes an agreement to have any issue of medical malpractice

decided by neutral arbitration and waiver of any right to a jury or court trial. Refer to the health

plan Evidence of Coverage booklet to determine if this provision is applicable to your plan.

Health Benefit Plan Enrollment Form - California Page 2