Health Benefits Election Form Fillable Template

See Dual Enrollment information on page 5. Standard Form 2809 Revised November 2015 If your enrollment is for Self Plus One or Self and Family complete the family member information as appropriate. Instructions for Completing SF 2809 Type or Print. We have not provided instructions for those items that have an explanation on the form. Part A Enrollee and Family Member Information You must complete this part. Note Civil Service Retirement System CSRS and Federal Employees Retirement System FERS annuitants and former spouses and children of CSRS/FERS annuitants -- Do not use this form. Instead use form OPM 2809 which is available at www. Health Benefits Election Form Item 9. Uses for Standard Form SF 2809 Use this form to Switch designated eligible family member or Enroll or reenroll in the FEHB Program or Elect not to enroll in the FEHB Program employees only or Change your FEHB enrollment or Suspend your FEHB enrollment annuitants or former spouses only. Agencies must distribute one copy of the completed SF 2809 to each of the following as appropriate e.g. child reaches age 26. Official Personnel Folder New Carrier Old Carrier Payroll Office Enrollee Privacy Act and Public Burden Statements The information you provide on this form is needed to document your enrollment in the Federal Employees Health Benefits Program under Chapter 89 title 5 U.S. Code. Annuitants Who Cancel Their Enrollment Part G Suspension of FEHB CSRS and FERS annuitants and their eligible family members should not use this form but use form RI 79-9 Health Benefits Cancellation/Suspension Confirmation which is available at 1-888-767-6738. It may also be shared and is subject to verification via paper electronic media or through the use of computer matching programs with national state local or other charitable or Social Security administrative agencies to determine and issue benefits under their programs or to obtain information necessary for determination or continuation of benefits under this program. In addition to the extent this information indicates a possible violation of civil or criminal law it may be shared and verified as noted above with an appropriate Federal state or local law enforcement agency. While the law does not require you to supply all the information requested on this form doing so will assist in the prompt processing of your We request that you provide your Social Security Number so that it may be used as your individual identifier in the FEHB Program and for other purposes. Executive Order 13478 November 18 2009 allows Federal agencies to use Social Security Numbers as individual identifiers to distinguish between people of same or similar names. Season only if the QLE caused all but one eligible family member to acquire other health insurance coverage. Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all in Premium Conversion Enrollment May Be Cancelled or Changed from Self and Family to Self Plus One or Self Only or from Self Plus One to Self Only at Any Time QLE s That Permit Enrollment or Change Self Enrolled to Time Limits From One Benefits Election Form With Your Employing Office Annuitant Includes Compensationers Note for enrolled survivor annuitants A change in family status based on additional family members can only occur if the additional 2A 2B death of family member adoption or divorce. days after the event. 2C Reenrollment of annuitant who suspended FEHB Plan and TRICARE for Life Peace Corps or CHAMPVA and who later involuntarily loses this May Reenroll days after involuntary loss of 2D ment to enroll in a Medicare Advantage plan Medicaid or similar State-sponsored program or to use TRICARE including Uniformed Services Family Health Plan or who wants to reenroll in the FEHB Program for any reason other than an involuntary loss of coverage.