Forms required for new enrollees in the Associate Faculty medical benefits program

** IMPORTANT: The forms on this page are all fillable and signable electronically. Once you've opened the form, please download and save the file before filling it out to access the signable electronic option.

 

 

 

  • Verification of Teaching Load Form - If you are working at least 40% load at SRJC, you don’t need to complete this form. You only need your other college to complete this form if you work between 20% load and 40% load at SRJC.

 

  • Kaiser enrollment form. * Be sure to check "HMO" or "Deductible plan" in Section A on enrollment form

 

          For Blue Shield HMO only – you must select a doctor when enrolling in this plan and include the doctor's IPA & PCP information on the enrollment form:

                    - IPA is the Medical Network/Group Name (like Providence Medical Network for instance) 

                    - PCP is the Primary Care Physician #

                      Here’s how to search on Blue Shield's website for the IPA and PCP information and to select a Blue Shield HMO doctor in your area:

                      Click on “Primary Care Physician”

                      Type in your location

                      Select Specialty, like “Family Practice”, “Internal Medicine”, etc.

Next to the doctor's name you'll see the medical network they belong to - you'll need to enter that in the "IPA" field on the enrollment form (example: Providence Medical Network)

Click on the doctor's name and you'll find the Primary Care Physician ID (PCP) that you'll need to enter on the enrollment form.

 

 

** IMPORTANT: The forms on this page are all fillable and signable electronically. Once you've opened the form, please download and save the file before filling it out to access the signable electronic option.