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Retiree Health Plan Forms
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| Enrollment |
- Notice of Open Enrollment - Retiree - There is an open enrollment that annually takes place in December for change of coverage effective January 1.
| Claim Forms |
- Medical Claim Form - Retiree - You or your health care provider can use this form to submit claims for medical care.
| Retiree Coverage |
- Waiver Of COBRA Rights - In order to obtain coverage under the Retiree Health Plan, you must agree to have your monthly payment for coverage deducted from your pension check, select your medical and dental coverage, and waive your right to COBRA coverage.
| Brochures & Communications |
- Copayments Brochure - This details the rates you need to pay for your coverage based on your family makeup and Medicare coverage.
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These printable forms are in PDF (Portable Document) format.
To read and print them, you need the free Adobe Acrobat Reader (which is probably already installed in your system). If you do need to install it, click the "Get Acrobat Reader" logo. |
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