RETIREE 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:

FOR RETIREES UNDER AGE 65:

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

 

 

FOR RETIREES OVER AGE 65:

Kaiser Senior Advantage enrollment form

 

Anthem CompanionCare enrollment form

 

To waive your medical insurance, please contact Christie Colón in Human Resources at ccolon@santarosa.edu or 707-527-4304.