Forms

Name and Marital Status Change Forms

• Marital Status Change Form - Personnel Services Form Should Be W/Personnel Services Items
• Name Change Form - Personnel Services Form Should Be W/Personnel Services Items

Active Employee

• Change of Home/Mailing and Emergency Contact Information
  (Please submit the completed form to your timekeeper or division personnel)
• HPN Enrollment Form (new)
• United Concordia Enrollment Form (new)
• Delta PPO Enrollment Form (new)
• Kaiser Enrollment Change Form (new)
• Active Enrollment/Change Form (new)
• UHC HMO Enrollment Form
• UHC PPO Enrollment Form
• Affidavit of Domestic Partnership Form
• Termination of Domestic Partnership Form

Retiree

• UHC PPO Pre-65 Retirees Enrollment Form
• United Concordia Enrollment Form
• HPN Enrollment Form for Nevada Residents only < 65 or Medicare B only (new)
• UHC HMO CA Enrollment Form (new)
• UHC HMO NV Enrollment Form (new)
• UHC Enrollment Form MAPD PPO (new)
• UHC Enrollment Form Active, Pre65 Fillable HMO (new)
• Kaiser Enrollment Change Form (new)
• Kaiser Senior Advantage (HMO) Form (new)
• Kaiser Senior Advantage HMO Form – Outside of California (new)
• Kaiser Senior Advantage Disenrollment Form (new)
• Retiree Enrollment/Change Form (new)
• Affidavit of Domestic Partner Form
• Termination of Domestic Partner Form