Official Federal Forms > US Office Of Personnel Management > OPM
Health Benefits Registration Form OPM 2809 - Official Federal Forms
| Health Benefits Registration Form Form. This is a national form and can be used in OPM US Office Of Personnel Management . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Health Benefits Election Form Who May Use OPM Form 2809 Form Approved: OMB No. 3206-0141 · · · · Annuitants Survivor annuitants Former spouses Children and former spouses who are eligible for temporary continuation of coverage Item 18. If a family member has Medicare, show which Parts he/she has on the line with his/her name. Check D if the family member has prescription drug coverage under the Medicare Part D Program. If a family member has TRICARE (see item 8), check the box. If a family member has other group insurance (private, state, Peace Corps, Medicaid), check the box. Give the name of any other insurance this family member has. Item 19. Item 20. Item 21. Instructions for Completing OPM 2809 Type or print firmly. We have not provided instructions for those items that require no further explanation. Part A -- Enrollee and Family Member Information. You must complete this part. Item 2. Item 5. Item 7. See the Privacy Act and Public Burden Statements on page 4. If you are separated but not divorced, you are still married. If you have Medicare, show which Parts you have. Also indicate whether you have prescription drug coverage under the Medicare Part D Program. TRICARE is a health care program for active duty and retired members of the uniformed services, their families, and survivors. This includes TRICARE for Life for members age 65 and older. If you have other group insurance (private, state, Medicaid, Peace Corps, CHAMPVA), check the box. Write the name of any other insurance you have. Family Members Eligible for Coverage Unless you are a former spouse or survivor annuitant, family members eligible for coverage under your Self and Family enrollment include your spouse and your unmarried dependent children under age 26. Eligible children include your legitimate or adopted children and recognized natural children, stepchildren or foster children, if they live with you in a regular parent-child relationship. A recognized natural child also may be included if a judicial determination of support has been obtained or you show that you provide regular and substantial support for the child. Other relatives (for example, your parents) are not eligible for coverage even if they live with you and are dependent upon you. Item 8. Item 9. Item 10. · If you are a former spouse or survivor annuitant, family members eligible for coverage under your Self and Family enrollment are the unmarried dependent natural or adopted children under age 26 of both you and your former or deceased spouse. Children whose marriage ends before they reach age 26 become eligible for coverage under your Self and Family enrollment from the date the marriage ends until they reach age 26. Complete information for family members only if your enrollment is for Self and Family. (If you need extra space for additional family members, list them on a separate sheet and attach.) Item 13. Please provide Social Security numbers for your dependents, if available. If not available, leave blank; benefits will not be withheld. (See Privacy Act Statement on page 4.) Provide the code which indicates the relationship of each eligible family member to you. · Item 16. In some cases, an unmarried, disabled child age 26 or older is eligible for coverage under your Self and Family enrollment if you provide adequate medical certification of a mental or physical handicap that existed before his or her 26th birthday and renders the child incapable of self-support. Note: The Office of Personnel Management can give you additional details about family member eligibility including any certification or documentation that may be required for coverage. Code Family Relationship 01 19 09 17 10 99 Spouse Unmarried dependent child under age 26 Adopted Child Stepchild Foster Child Unmarried disabled child over age 26 incapable of selfsupport because of a physical or mental disability that began before age 26. Part B -- Present Plan. You must complete this part if you are changing, canceling, or suspending your enrollment. Item 1. Item 2. Enter the name of the plan you are enrolled in, as shown on the front cover of the plan brochure. Enter the enrollment code of the plan. Part C -- New Plan. Complete this part to enroll or change your enrollment in the Federal Employees Health Benefits (FEHB) Program. Previous editions are not usable. 1 American LegalNet, Inc. www.FormsWorkFlow.com OPM Form 2809 Revised April 2011 Items 1 and 2. Enter the plan name and enrollment code as shown on the front cover of the brochure of the plan you want to be enrolled in. The enrollment code shows the plan and option you are electing and whether you are enrolling for Self Only or Self and Family. · · · TRICARE (including Uniformed Services Family Health Plan or TRICARE for Life), Peace Corps, or CHAMPVA To enroll in a Health Maintenance Organization (HMO), you must live in the geographic area specified by the carrier. To enroll in an employee organization plan, you must be or become a member of the plan's sponsoring organization, as specified by the carrier. Your signature in Part F authorizes deductions from your annuity to cover your cost of the enrollment you elect in this item, unless you are required to make direct payments. You can reenroll in the FEHB Program if your other coverage ends. If your coverage ends involuntarily, you can reenroll 31 days before through 60 days after loss of coverage. If you want to reenroll in the FEHB Program for a reason other than an involuntary loss of coverage, you may do so during the next open season. You must submit documentation of eligibility for coverage under the non-FEHB Program to the Office of Personnel Management. Initial the last box only if you wish to cancel your FEHB enrollment. Also enter your present enrollment code in Part B. Be sure to read the information below in the paragraph titled "Annuitants Who Cancel Their Enrollment." Part D -- Event Code. Item 1. Enter the event code that permits you to enroll, change, or cancel. (See the Table of Permissible Changes in Enrollment starting on page 5.) Annuitants Who Cancel Their Enrollment Generally, you cannot reenroll as an annuitant unless you are continuously covered as a family member under another person's enrollment in the FEHB Program during the period between your cancellation and reenrollment. OPM can advise you on events that allow eligible annuitants to reenroll. If you cancel your enrollment because you are covered under another FEHB enrollment, you ca
|
|||||||
