| Enrollment and Change Forms |
| ● New Hire Enrollment Form - revised 12/29/2011 |
| ● Midyear Change Form - revised 8/15/2011 |
| ● Open Enrollment Change Form - revised 8/19/2011 |
| ● Long Term Care Enrollment Form |
| ● Are you eligible for OEBB benefits through HB 2557? Click Here. |
| Optional Insurance |
| ● Beneficiary Designation Form |
| ● Medical History Statement for life & disability insurance (online) |
| ● Medical History Statement for long term care insurance (pdf) |
| ● Terminate Long Term Care Insurance Form |
● Click here for more forms and information on life & disability insurance
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● Click here for more forms and information on long term care insurance
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| Covering Others |
| ● Affidavit of Domestic Partnership |
| ● Termination of Domestic Partnership Form |
| Appeal and Public Comment |
| ● Appeal Form Review the OEBB Appeal Policy |
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| Reimburse your unpaid claims (no guarantee of payment) |
| ● Reimbursement Form - Kaiser Permanente |
| ● Reimbursement Forms - ODS medical, dental, vision and pharmacy |
| ● Reimbursement Form - Providence |
| Transition of Care |
| ● Transition of Care Request Form - ODS |
| ● Transition of Care Request Form - Providence |
| Weight Watchers |
● Online subscription Proof of Participation Form
Microsoft Word format (computer fillable form)
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