Fillable Hca Pebb - Employee Enrollment Change Form

2016 Employee Enrollment/Change

Subscriber’s last name

First name

Middle initial Social Security number

Section 6: Signature

Required

By signing this form, I declare that the information I have provided is true, complete, and correct. If it isn’t, or if I do not update

this information within the timelines in PEBB rules, to the extent permitted by federal and state laws, I must repay any claims

paid by my health plan(s) or premiums paid on my behalf. My family members and I may also lose PEBB benefits as of the last

day of the month we were eligible. To the extent permitted by law, PEBB or my employer may retroactively terminate coverage

for me and my dependents if I intentionally misrepresent eligibility, or do not fully pay premiums when due. In addition, I

understand that knowingly providing false, incomplete, or misleading information to an insurance company for the purpose of

defrauding the company is a crime, and can result in imprisonment, fines, denial of PEBB benefits, and loss of my job.

If adding a registered domestic partner to my account, I declare that my domestic partner and I have registered through the

Washington Secretary of State’s Office or another state.

Enrollment is not complete until verification of the family member’s eligibility is successful. I understand that if I’m applying to

add a dependent to my PEBB coverage, I must provide copies of documents that verify the dependent’s eligibility within PEBB’s

enrollment timelines, or the dependent will not be enrolled.

Employees must enroll in PEBB dental, basic life, and basic long-term disability insurance. However, employees may waive

PEBB medical if they are enrolled in other employer-based group medical insurance, TRICARE, or Medicare. If I waive medical,

I understand I can enroll during the annual open enrollment period or within 60 days after a special open enrollment event as

defined in PEBB rules. If I waive medical for myself, I cannot enroll my eligible family members in medical.

I allow my employer to deduct money from my earnings to pay for insurance coverage and any applicable surcharges.

If I am enrolling in a consumer-directed health plan with a health savings account (HSA), I must meet HSA eligibility conditions.

I understand that my employer will contribute to an HSA on my behalf based on the information I have provided, and that there

are limits to these contributions and my HSA contributions (if any) under federal tax law.

I understand if I am enrolled in retiree life insurance, I may keep it by completing and submitting the Employee Life and AD&D

Insurance Enrollment/Change Form and having the premiums deducted from my paycheck.

This form replaces all Employee Enrollment/Change forms previously submitted.

HCA’s Privacy Notice: We will keep your information private as allowed by law.

To see our Privacy Notice, go to

Subscriber’s signature

Date ______________________________

_________________________________________________

Please sign and date this form.

Return completed form and documentation to your personnel, payroll, or benefits office.

2016 PEBB Medical Contractors

2016 PEBB Dental Contractors

Group Health Cooperative

DeltaCare, administered by

320 Westlake Ave. N., Suite 100, Seattle, WA 98109-5233

Delta Dental of Washington

1-888-901-4636 or TTY 1-800-833-6388

9706 Fourth Avenue NE, Seattle, WA 98115-2157

1-800-650-1583

Group Health Options Inc.

320 Westlake Ave. N, Suite 100, Seattle, WA 98109-5233

Uniform Dental Plan, administered by

1-888-901-4636 or TTY 1-800-833-6388

Delta Dental of Washington

9706 Fourth Avenue NE, Seattle, WA 98115-2157

Kaiser Foundation Health Plan of the Northwest

1-800-537-3406

500 NE Multnomah St., Suite 100, Portland, OR 97232-2099

1-800-813-2000 or TTY 711

Willamette Dental of Washington, Inc.

6950 NE Campus Way, Hillsboro, OR 97124-5611

Uniform Medical Plan, administered by Regence BlueShield

1-855-4DENTAL (1-855-433-6825)

1800 Ninth Avenue, Suite 235, Seattle, WA 98101

1-888-849-3681 or TTY 711

Hca Pebb - Employee Enrollment Change Form - 2016 Page 7

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