Web• If you are deferring enrollment in PEBB retiree insurance coverage, complete required sections below and Sections 1 and 7. • If you are enrolling a dependent with a disability age 26 or older, submit a completed . Certification of Dependent With a Disability form and return as instructed on the form. Webplease use the PEBB Retiree Change Form (form E). All forms and documents mentioned and a self-paced tutorial about how to complete this form . are available on HCA’s website …
When eligibility for benefits ends Washington State Health Care …
WebComplete this form to make changes to an existing retiree account. If you are newly eligible and applying to enroll in or defer PEBB retiree insurance coverage, or enrolling after deferring, please submit the PEBB Retiree Election Form (form A). This form replaces all … WebThis form cannot be signed more than 90 days before the effective date of this coverage. (See Statement of Understanding on the next page for Medicare Advantage Plan coverage effective date.) If you are a retiree receiving benefits from the Department of Retirement Systems (DRS), the PEBB Program may share your information with DRS. lynn white sox pitcher
2024 Retiree Medicare Advantage Election Form (form C)
WebI acknowledge I have the right to appeal this and any future eligibility decisions for PEBB benefits made by a PEBB-participating employing agency through the PEBB appeals process (Chapter 182-16 WAC). I understand the PEBB appeals process begins with requesting a review from my employer. WebNew retirees An eligible retiree may enroll in PEBB retiree benefits. Retirees may choose: > A full-time or part-time plan > Medical, dental or vision-only benefits > All available core benefits. Annual retiree “plan change period” The annual plan change period runs Oct. 1-31, 2024. Retirees who selected medical the first year must actively Web2024 PEBB Employee Enrollment/ Change Form. 1 This field is required for health care services. 2 Gender X means a gender that is not exclusively male or female. This field is … lynn white take your time