Official Federal Forms > US Office Of Personnel Management > Standard
Employee Health Benefits Registration Form SF 2809 - Official Federal Forms
| Employee Health Benefits Registration Form Form. This is a national form and can be used in Standard US Office Of Personnel Management . |
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Health Benefits Election Form Form Approved: OMB No. 3206-0160 Uses for Standard Form (SF) 2809 Use this form to: · · · · · Enroll or reenroll in the FEHB Program; or Elect not to enroll in the FEHB Program (employees only); or Change your FEHB enrollment; or Cancel your FEHB enrollment; or Suspend your FEHB enrollment (annuitants or former spouses only). Instructions for Completing SF 2809 Type or Print Firmly. We have not provided instructions for those items that have an explanation on the form. 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 5. If you are separated but not divorced, you are still married. If you have Medicare, show which Parts you have. If you complete this form after November 15, 2005, 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 65 and over. If you have other group insurance (private, state, Medicaid, CHAMPVA), check the box. Write the name of any other insurance you have. Who May Use SF 2809 1. Employees eligible to enroll in or currently enrolled in the FEHB Program, including temporary employees eligible under 5 U.S.C. 8906a. Employees automatically participate in premium conversion unless they waive it, see page 7. 2. Annuitants (other than Civil Service Retirement System [CSRS] and Federal Employees Retirement System [FERS] annuitants) eligible to enroll in or currently enrolled in the FEHB Program, including individuals receiving monthly compensation from the Office of Workers' Compensation Programs (OWCP). Note: Civil Service Retirement System (CSRS) and Federal Employees Retirement System (FERS) annuitants and former spouses and children of CSRS/FERS annuitants -- Do not use this form. Instead, call the Retirement Information Office toll-free at 1-888-767-6738. Customers within the local calling distance to Washington, DC, should call 202-606-0500. 3. Former spouses eligible to enroll in or currently enrolled in the FEHB Program under the Spouse Equity law or similar statutes. 4. Individuals eligible for Temporary Continuation of Coverage (TCC) under the FEHB Program, including: Item 8. Item 9. Item 10. 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 5.) Provide the code which indicates the relationship of each eligible family member to you. Code Family Relationship Item 16. · · · Former employees (who separated from service); Children who lose FEHB coverage; and Former spouses who are not eligible for FEHB under item 3 above. 01 19 09 17 10 99 Spouse Unmarried dependent child under age 22 Adopted Child Stepchild Foster Child Unmarried disabled child over age 22 incapable of self support because of a physical or mental disability that began before age 22. This form supersedes all previous editions of SF 2809 and SF 2809-1. 1 Standard Form 2809 Revised October 2004 American LegalNet, Inc. www.FormsWorkFlow.com Item 18. If a family member has Medicare, show which Parts he/she has on the line with his/her name. If you complete this form after November 15, 2005, also indicate whether you have 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, Medicaid), check the box. Give the name of any other insurance this family member has. Part C -- New Plan. Complete this part to enroll or change your enrollment in the FEHB Program. Items 1 and 2. Enter the plan name and enrollment code from 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. Item 19. Item 20. Item 21. To enroll in a Health Maintenance Organization (HMO), you must live (or in some cases work) in a 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 H authorizes deductions from your salary, annuity, or compensation to cover your cost of the enrollment you elect in this item, unless you are required to make direct payments to the employing office. 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 22. Eligible children include your legitimate or adopted children; and recognized children born out of wedlock, stepchildren or foster children, if they live with you in a regular parent-child relationship. A recognized child born out of wedlock 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. Part D -- Event Code. Item 1. Enter the event code that permits you to enroll, change, or cancel based on a qualifying life event (QLE) from the Table of Permissible Changes in Enrollment that applies to you. · 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 22 of both you and your former or deceased spouse. Children whose marriage ends before they reach age 22 become eligible for coverage under your Self and Family enrollment from the date the marriage ends until they reach age 22. Explanation of Table of Permissible Changes in Enrollment The tables on pages 7 through 14 illustrate when: an employee who participates in premium conversion; annuitant; former spouse; person eligible for TCC; or employee who waived participation in premium conversion may enroll or change enrollment. The tables show those p
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