Form PERS-HBD-21 "Direct Payment Authorization" - California

What Is Form PERS-HBD-21?

This is a legal form that was released by the California Public Employees' Retirement System - 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 October 1, 2017;
  • The latest edition provided by the California Public Employees' Retirement System;
  • 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 PERS-HBD-21 by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Download Form PERS-HBD-21 "Direct Payment Authorization" - California

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C
Health Account Management Division
P.O. BOX 942715, Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | TTY (877) 249-7442
FAX (800) 959-6545 |
www.calpers.ca.gov
DIRECT PAYMENT AUTHORIZATION
PERS-HBD-21 (Rev 10/17)
PART A
EMPLOYEE INFORMATION
1. SOCIAL SECURITY NUMBER
2. NAME
(FIRST)
(MIDDLE)
(LAST)
3. PRIMARY PHONE NUMBER
4. HOME ADDRESS (STREET)
(CITY)
(STATE)
(ZIP)
PART B
CARRIER PREMIUM
5A. DIRECT PAYMENT TO: (CARRIER NAME AND ADDRESS)
5b. PLAN CODE
6a. GROSS PREMIUM
$
6b. MONTH (alpha)
6c. YEAR (numerical)
THE ABOVE PREMIUM IS PAYABLE TO CARRIER INDICATED, BEGINNING WITH PREMIUM MONTH OF:
I agree to pay the total premium direct to the health plan carrier listed above before the tenth of each month which precedes the premium month.
th
th
(For example, the June premium would be due by May 10
; the July premium would be due by June 10
.)
Note: I understand that failure to pay premiums will result in the suspension of my coverage. I also understand that the carrier will not bill me for
premium and no employer contribution is available for direct payment.
6d. EMPLOYEE SIGNATURE (See reverse for important information and disclosure statement.)
6e. DATE
PART C
REASON FOR DIRECT PAY
7.
8.
9.
LEAVE OF ABSENCE
APPEAL FOR DISMISSAL
SUSPENSION
10.
11.
12.
ON WORKER’S COMP (ELECTED NOT
PERMANENT INTERMITTENT
ROLL CODE 9
TO SUPPLEMENT) OR CLAIM PENDING
(OFF- PAY)
13.
14.
PLEASE EXPLAIN
OTHER (INSUFFICIENT EARNINGS,
APPLIED FOR DISABILITY RETIREMENT
PENDING NDI)
PART D
AGENCY INFORMATION
15A. NAME OF EMPLOYING AGENCY
15b. EMPLOYEE POSITION INFORMATION
AGENCY
UNIT
CLASS
SERIAL
BARG.
UNIT
16. DATES OF ABSENCE (numerical)
17. LAST PREMIUM DEDUCTION PAY PERIOD
MONTH
DAY
YEAR
MONTH
DAY
YEAR
MONTH (alpha)
YEAR (numerical)
FROM:
TO:
18. SIGNATURE OF HEALTH BENEFITS OFFICER
19. DATE
20. PHONE NUMBER
C
Health Account Management Division
P.O. BOX 942715, Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | TTY (877) 249-7442
FAX (800) 959-6545 |
www.calpers.ca.gov
DIRECT PAYMENT AUTHORIZATION
PERS-HBD-21 (Rev 10/17)
PART A
EMPLOYEE INFORMATION
1. SOCIAL SECURITY NUMBER
2. NAME
(FIRST)
(MIDDLE)
(LAST)
3. PRIMARY PHONE NUMBER
4. HOME ADDRESS (STREET)
(CITY)
(STATE)
(ZIP)
PART B
CARRIER PREMIUM
5A. DIRECT PAYMENT TO: (CARRIER NAME AND ADDRESS)
5b. PLAN CODE
6a. GROSS PREMIUM
$
6b. MONTH (alpha)
6c. YEAR (numerical)
THE ABOVE PREMIUM IS PAYABLE TO CARRIER INDICATED, BEGINNING WITH PREMIUM MONTH OF:
I agree to pay the total premium direct to the health plan carrier listed above before the tenth of each month which precedes the premium month.
th
th
(For example, the June premium would be due by May 10
; the July premium would be due by June 10
.)
Note: I understand that failure to pay premiums will result in the suspension of my coverage. I also understand that the carrier will not bill me for
premium and no employer contribution is available for direct payment.
6d. EMPLOYEE SIGNATURE (See reverse for important information and disclosure statement.)
6e. DATE
PART C
REASON FOR DIRECT PAY
7.
8.
9.
LEAVE OF ABSENCE
APPEAL FOR DISMISSAL
SUSPENSION
10.
11.
12.
ON WORKER’S COMP (ELECTED NOT
PERMANENT INTERMITTENT
ROLL CODE 9
TO SUPPLEMENT) OR CLAIM PENDING
(OFF- PAY)
13.
14.
PLEASE EXPLAIN
OTHER (INSUFFICIENT EARNINGS,
APPLIED FOR DISABILITY RETIREMENT
PENDING NDI)
PART D
AGENCY INFORMATION
15A. NAME OF EMPLOYING AGENCY
15b. EMPLOYEE POSITION INFORMATION
AGENCY
UNIT
CLASS
SERIAL
BARG.
UNIT
16. DATES OF ABSENCE (numerical)
17. LAST PREMIUM DEDUCTION PAY PERIOD
MONTH
DAY
YEAR
MONTH
DAY
YEAR
MONTH (alpha)
YEAR (numerical)
FROM:
TO:
18. SIGNATURE OF HEALTH BENEFITS OFFICER
19. DATE
20. PHONE NUMBER
Direct Pay Authorization Information
You may continue your health coverage while on temporary leave by paying the entire monthly premium directly to
your health plan.
You are eligible for direct payment if you:
go on leave of absence without pay;
take a temporary disability leave and do not use sick leave or vacation;
are waiting for approval of a disability retirement or a “regular” service retirement;
are waiting for approval of Non-Industrial Disability Insurance benefits;
are suspended from your job or you institute legal proceedings appealing a dismissal from your job; or
are a State Permanent-Intermittent employee eligible for health benefits but in a non-pay status. (Direct pay
may be elected only through the end of the qualifying control period.)
Requests for direct payments must be received by the Office of Employer and Member Health Services prior to the
beginning of your leave. If you do not elect the direct payment option while on leave of absence, your benefits will
stop. They will be reinstated when you return to pay status, if your earnings are sufficient to cover your share of the
monthly premium.
Completing the HBD-21 (Direct Payment Authorization) Form
Contact your Personnel Office for assistance in completing your form. Forms must be completed before your group
coverage terminates. Late forms will not be accepted. In addition, the carrier must receive the form and your
payment in order to continue your coverage.
While in off-pay status, you may add or delete family members. To do so, complete and submit a Health Benefit Plan
Enrollment Form (PERS -HBD-12).
You must pay the premium for the pay period in which you return to work.
IMPORTANT INFORMATION
Submission of the requested information is mandatory.
The information requested is collected pursuant to the
Government Code Sections (20000. et seq.) and will be used for administration of the Board’s duties under the
Retirement Law, the Social Security Act, and the Public Employees’ Medical and Hospital Care Act, as the case may
be. Portions of this information may be transferred to another governmental agency (such as your employer) but
only in strict accordance with current statutes regarding confidentiality. Failure to supply the information may result in
the System being unable to perform its functions regarding your status.
DISCLOSURE OF SOCIAL SECURITY NUMBERS
Section 7(b) of the Privacy Act of 1974 (Public Law 93—579) requires that any federal, state, or local governmental
agency which requests an individual to disclose his 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 Office of Employer and Member Health Services of the California Public Employees’ Retirement System
requests 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 other agencies for identification purposes, the Office of Employer
and Member Health Services may be unable to verify eligibility for benefits without the S ocial S ecurity account
number.
The Office of Employer and Member Health Services of the California Public Employees’ Retirement System uses
social security account numbers for the following purposes:
1. Enrollee identification for eligibility processing and eligibility verification
2. Payroll deduction and state contribution for state employees
3. Billing of contracting agencies for employee and employer contributions
4. Reports to the California Public Employees’ Retirement System and other state agencies
5. Coordination of benefits among carriers
You have the right to review your membership files maintained by the System. For questions concerning your rights
under the Information Practices Act of 1977, please contact the Information Practices Act Coordinator, CalPERS,
P.O. Box 942702, Sacramento, CA 94229-2702.
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
Social Security numbers are used for the
following purposes:
The information requested is collected pursuant
1. Enrollee identification
to the Government Code (sections 20000 et seq.)
2. Payroll deduction/state contributions
and will be used for administration of Board
3. Billing of contracting agencies for employee/
duties under the Retirement Law, the Social
employer contributions
Security Act, and the Public Employees’ Medical
4. Reports to CalPERS and other state agencies
and Hospital Care Act, as the case may be.
5. Coordination of benefits among carriers
Submission of the requested information is
6. Resolving member appeals, complaints,
mandatory. Failure to comply may result in
or grievances with health plan carriers
CalPERS being unable to perform its functions
regarding your status.
Information Disclosure
Please do not include information that is
Portions of this information may be transferred
not requested.
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
Social Security Numbers
in strict accordance with current statutes
regarding confidentiality.
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
Your Rights
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
You have the right to review your membership
Social Security number has already been provided,
files maintained by the System. For questions
disclosure is voluntary. Due to the use of Social
about this notice, our Privacy Policy, or your rights,
Security numbers by other agencies for
please write to the CalPERS Privacy Officer at
identification purposes, we may be unable to
400 Q Street, Sacramento, CA 95811 or call us
verify eligibility for benefits without the number.
at 888 CalPERS (or 888-225-7377).
May 2016
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