ENROLLMENT FORMS

All enrollment forms should be submitted to Christie Colón in Human Resources

Don't forget to provide the dependent eligibility documentation if you're adding a dependent. 

 

These forms are fillable and signable. Once you've opened the form, please click "Download" to download the signable version:

 

MEMBERSHIP CHANGE FORM

Making changes to your current medical plan (like adding or deleting a dependent)? Please fill out the Membership Change form.

 

BLUE SHIELD ENROLLMENT FORM

Use this form to enroll for the first time and follow these instructions:

  • Blue Shield PPO or HSA – you must write HSA or PPO in the top margin on the form
  • Blue Shield HMO – 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 Group Name
    • 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 here
      •  Click on “Primary Care Physician”
      • Type in your location
      • Select Specialty, like “Family Practice”, “Internal Medicine”, etc.

 

KAISER ENROLLMENT FORM

Use this form to enroll for the first time and follow these instructions: 

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

 

WAIVE MEDICAL INSURANCE

  • If you work more than 90% and want to waive your health insurance, please fill out these three forms.
  • If you work more than 50% but less than 90%, please fill out this form to waive your health insurance.

 

VISION INSURANCE

Vision insurance is only for Contract Faculty, Classified and Management employees. Associate Faculty are not eligible for VSP vision insurance.

Making changes or enrolling in the vision insurance plan? Please fill out the form above.