Form STD696 "Dental Plan Direct Payment Authorization" - California

What Is Form STD696?

This is a legal form that was released by the California Department of General Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2008;
  • The latest edition provided by the California Department of General Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form STD696 by clicking the link below or browse more documents and templates provided by the California Department of General Services.

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Download Form STD696 "Dental Plan Direct Payment Authorization" - California

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STATE OF CALIFORNIA í DEPARTMENT OF PERSONNEL ADMINISTRATION
DENTAL PLAN DIRECT PAYMENT AUTHORIZATION
STD 696 (REV 5/2008)
INSTRUCTIONS: Review General Instructions on the reverse of this form. Then, complete the following parts of this form for employees enrolled in a dental
plan who are going on non-pay status (i.e., the employee will not receive a warrant from the State Controller's Office).
1. Parts A and B and Part D, Item 16-Employees who do not wish to continue dental coverage.
2. Parts A, C and D-Employees who wish to continue dental coverage.
PLEASE TYPE OR PRINT USING BALL POINT PEN
PART A
EMPLOYEE INFORMATION
1.
SOCIAL SECURITY NUMBER
NAME (First, Middle, Last)
DATE OF BIRTH
2.
3.
(SEE REVERSE FOR DISCLOSURE STATEMENT)
4.
HOME PHONE NUMBER
5.
MAILING ADDRESS (Street, City, State, Zip Code)
6.
DENTAL CARRIER
7.
CARRIER ADDRESS
Check here for 120-day
Death Benefit
PART B
COVERAGE NOT RETAINED
8.
I do not wish to continue my dental plan coverage while off pay status. I understand my coverage will terminate at the
end of the first full month I am off pay status and will not resume until the beginning of the second month after I return
to pay status.
Employee Signature
Date
PART C
PREMIUM PAYMENT AGREEMENT
9.
Complete the premium calculations below. Direct payment may not exceed one year for any carrier. Payment must be for a three-month period
or the length of the absence, whichever is less. The initial payment is due to the carrier on the first day of the month following the first full month
the employee is off pay status. Installment and/or final payment(s) (if applicable) will then be due to the carrier on the first of each succeeding
three-month period.
INITIAL PAYMENT (Submit directly to carrier with this form):
$
Due Date
9.A.
INSTALLMENT PAYMENT(S) (IF APPLICABLE):
$
Due Date(s)
9.B.
FINAL PAYMENT (IF APPLICABLE):
$
Due Date
9.C.
I agree to pay all premiums directly to the dental plan carrier listed above by the specified due date(s) to cover the cost of enrollment as it
10.
is now or as it may be in the future. I understand that failure to pay premiums will result in suspension of my coverage. I also understand
that the carrier will not bill me for any premium and no employer contribution will be made during the direct payment period.
Employee Signature
Date
PART D
AGENCY INFORMATION (To be completed by the Personnel Office)
12. EMPLOYEE POSITION INFORMATION
11. NAME OF EMPLOYING AGENCY
BARG.
AGENCY
UNIT
DESIGNATION
UNIT
13. ADDRESS OF EMPLOYING AGENCY
14. REASON FOR DIRECT PAYMENT
(SEE REVERSE FOR LIST OF SITUATIONS)
15. DATES OF ABSENCE
16. PAY PERIOD OF LAST PREMIUM DEDUCTION
MONTH
YEAR
MONTH
DAY
YEAR
MONTH
DAY
YEAR
FROM:
TO:
19. DATE
17. AUTHORIZED AGENCY SIGNATURE
18. TELEPHONE NUMBER
1-CARRIER COPY
2-EMPLOYEE COPY
3-DEPARTMENT COPY
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STATE OF CALIFORNIA í DEPARTMENT OF PERSONNEL ADMINISTRATION
DENTAL PLAN DIRECT PAYMENT AUTHORIZATION
STD 696 (REV 5/2008)
INSTRUCTIONS: Review General Instructions on the reverse of this form. Then, complete the following parts of this form for employees enrolled in a dental
plan who are going on non-pay status (i.e., the employee will not receive a warrant from the State Controller's Office).
1. Parts A and B and Part D, Item 16-Employees who do not wish to continue dental coverage.
2. Parts A, C and D-Employees who wish to continue dental coverage.
PLEASE TYPE OR PRINT USING BALL POINT PEN
PART A
EMPLOYEE INFORMATION
1.
SOCIAL SECURITY NUMBER
NAME (First, Middle, Last)
DATE OF BIRTH
2.
3.
(SEE REVERSE FOR DISCLOSURE STATEMENT)
4.
HOME PHONE NUMBER
5.
MAILING ADDRESS (Street, City, State, Zip Code)
6.
DENTAL CARRIER
7.
CARRIER ADDRESS
Check here for 120-day
Death Benefit
PART B
COVERAGE NOT RETAINED
8.
I do not wish to continue my dental plan coverage while off pay status. I understand my coverage will terminate at the
end of the first full month I am off pay status and will not resume until the beginning of the second month after I return
to pay status.
Employee Signature
Date
PART C
PREMIUM PAYMENT AGREEMENT
9.
Complete the premium calculations below. Direct payment may not exceed one year for any carrier. Payment must be for a three-month period
or the length of the absence, whichever is less. The initial payment is due to the carrier on the first day of the month following the first full month
the employee is off pay status. Installment and/or final payment(s) (if applicable) will then be due to the carrier on the first of each succeeding
three-month period.
INITIAL PAYMENT (Submit directly to carrier with this form):
$
Due Date
9.A.
INSTALLMENT PAYMENT(S) (IF APPLICABLE):
$
Due Date(s)
9.B.
FINAL PAYMENT (IF APPLICABLE):
$
Due Date
9.C.
I agree to pay all premiums directly to the dental plan carrier listed above by the specified due date(s) to cover the cost of enrollment as it
10.
is now or as it may be in the future. I understand that failure to pay premiums will result in suspension of my coverage. I also understand
that the carrier will not bill me for any premium and no employer contribution will be made during the direct payment period.
Employee Signature
Date
PART D
AGENCY INFORMATION (To be completed by the Personnel Office)
12. EMPLOYEE POSITION INFORMATION
11. NAME OF EMPLOYING AGENCY
BARG.
AGENCY
UNIT
DESIGNATION
UNIT
13. ADDRESS OF EMPLOYING AGENCY
14. REASON FOR DIRECT PAYMENT
(SEE REVERSE FOR LIST OF SITUATIONS)
15. DATES OF ABSENCE
16. PAY PERIOD OF LAST PREMIUM DEDUCTION
MONTH
YEAR
MONTH
DAY
YEAR
MONTH
DAY
YEAR
FROM:
TO:
19. DATE
17. AUTHORIZED AGENCY SIGNATURE
18. TELEPHONE NUMBER
1-CARRIER COPY
2-EMPLOYEE COPY
3-DEPARTMENT COPY
DISCLOSURE OF SOCIAL SECURITY NUMBERS
1
Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any governmental agency which requests an individual to
disclose his/her social security account number shall inform that individual whether that disclosure is mandatory or voluntary, by
which statutory or other authority such number is solicited, and what uses will be made of it.
The dental insurance carriers under contract with the State of California request each enrollee's social security account number on
a voluntary basis. However, it should be noted that due to the use of social security account numbers by the dental carriers for
identification purposes, the dental insurance carriers may be unable to verify dental plan enrollment and ensure continuation of
dental coverage without disclosure of the social security number.
Each dental insurance carrier may use the social security account number for enrollee verification and for eligibility processing only.
DENTAL PLAN DIRECT PAYMENT GENERAL INSTRUCTIONS
I.
TYPES OF SITUATIONS NECESSITATING DIRECT PAYMENT BY THE EMPLOYEE TO CONTINUE COVERAGE INCLUDE
THE FOLLOWING:
1. Leave of absence other than NDI, IDL, or Workers' Compensation with Supplementation.
2. Appeal of involuntary termination. (COBRA provisions apply; direct payment provisions are not applicable.)
3. Suspension of one or more complete pay periods.
4. Permanent Intermittent, off pay status. (COBRA provisions apply; direct payment provisions are not applicable.)
5. Applied for Disability Retirement, off pay status.*
6. Awaiting IDL determination when all sick leave and vacation credits have been exhausted.*
7. For survivor of employee.
8. Under approved SDI benefits.
* NOTE: Employees enrolled in a dental plan who are on non-pay status while awaiting a disability determination must direct pay if
they wish to have their coverage continued. At such time as the State Controller's Office (SCO) issues warrants which
include dental deductions for the months when the employee has made direct payment, the employee may apply directly
to the carrier for a refund.
II. EMPLOYEES WHO DO NOT ELECT TO RETAIN DENTAL COVERAGE WHILE ON NON-PAY STATUS ARE SUBJECT TO
THE FOLLOWING TERMS:
1. Coverage will automatically resume effective the first day of the second month following the employee's return to pay status.
2. Deductibles accrued prior to the non-payment period will not be carried over.
3. Portions of qualifying time accrued for required waiting periods prior to the non-payment period will not be carried over.
III. EMPLOYEES WHO ELECT TO RETAIN DENTAL COVERAGE WHILE ON NON-PAY STATUS ARE SUBJECT TO THE
FOLLOWING TERMS:
1. It is the employee's responsibility to provide the carrier with a copy of the completed Direct Payment Authorization Form
(STD. 696) and all payments by the established due date(s). Do not send this Authorization to the SCO or to the Department of
Personnel Administration.
2. If the employee wishes to add or delete a spouse or dependent(s) he/she must notify the departmental Health Benefits Officer,
complete a new State Dental Plan Enrollment Authorization (STD. 692) and mail a completed copy directly to the carrier.
3. In the event the employee returns to pay status prior to completion of the period for which he/she has already made direct
payment, the employee must contact the carrier directly to request a premium refund for any full, unused months of coverage.
4. Employees in Bargaining Units 5 and 6 must make all arrangements for direct payment through their exclusive representative.
IV. THE DEPARTMENT'S ROLE IN THE DIRECT PAYMENT PROCESS INCLUDES THE FOLLOWING:
1. Ensuring that this form is completed for all employees who are enrolled in a dental plan and on non-pay status for one or more
complete pay periods.
2. Providing the employee with both the carrier and employee copies of the completed Direct Payment Authorization Form
(STD. 696) and placing the departmental copy in the employee's personnel file.
3. Upon request of the employee, assisting in the addition or deletion of an eligible spouse or dependent(s) by completing a State
Dental Plan Enrollment Authorization (STD. 692) and routing the original to the Controller's Office for processing.
4. Referring all Bargaining Unit 5 and 6 employees who wish to make direct payment to their exclusive representative.
V. EXAMPLES OF DIRECT PAYMENT CALCULATIONS:
1. An employee and spouse are enrolled in the ABC dental plan. The employee goes on a 6-month unpaid leave beginning
October 1, 2008, and elects to retain dental coverage. (Assuming employee + 1 rate of $85.12.)
INITIAL PAYMENT: $255.36. DUE DATE: Nov. 1, 2008.
INSTALLMENT PAYMENT(S): $-0-. DUE DATE(S): None.
FINAL PAYMENT: $255.36. DUE DATE: Feb. 1, 2009.
2. An employee, her spouse and child are enrolled in the ABC dental plan. On July 10, 2008, the employee has a baby and begins
a one-year maternity leave. She elects to retain her dental coverage, goes on NDI until August 22, 2008 and then non-pay
status for the duration of the leave ending July 9, 2009. (Assuming employee + 2 rate of $123.75.)
INITIAL PAYMENT: $371.25. DUE DATE: Oct. 1, 2008.
INSTALLMENT PAYMENT(S): $371.25. DUE DATE(S): Jan. 1, 2009 and April 1, 2009.
FINAL PAYMENT: $123.75. DUE DATE: July 1, 2009.
STD 696 (REV. 5/2008)
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