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.

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 on “Primary Care Physician”
  - Type in your location
  - Select Specialty, like “Family Practice”, “Internal Medicine”, etc.

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 the enrollment form

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