Instructions for Form HBD-12 "Health Benefits Plan Enrollment for Active Employees" - California

This document contains official instructions for Form HBD-12, Health Benefits Plan Enrollment for Active Employees - a form released and collected by the California Public Employees' Retirement System. An up-to-date fillable Form HBD-12 is available for download through this link.

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Health Benefits Plan Enrollment for Active Employees (HBD-12) Instructions
Contact your agency's personnel office if you have questions about your health enrollment. To enroll or decline enrollment
in the CalPERS Health Program or to make changes to your health plan, you must submit an HBD-12 form to your Health
Benefits Officer (HBO). If you have more than five dependents, please complete another HBD-12 form. Your agency's
personnel office will retain your original HBD-12 form and supporting documentation or affidavits in your employee file and
will provide a copy to you.
SECTION A: Applicant Information
Enter your basic information as indicated. If you are using your work zip code for health eligibility, please include your work
zip code in part 8.
SECTIONS B & C: Type of Action and Type of Permitting Event
Select the the type of action and your permitting event. Below is a list of permitting events and required documentation. The
required documents in the table below are not inclusive; you may need to submit additional documentation upon your
HBO's request.
Permitting Event
Required Documentation
New Employee
• Health Benefits Plan Enrollment Form (HBD-12)
New Contracting Agency
• Health Benefits Plan Enrollment Form (HBD-12)
• Marriage Certificate or
• Declaration of Domestic Partnership from the
Marriage or Domestic Partnership
Secretary of State's Office
Delete Dependent Due to Death
• Death Certificate
• Divorce Decree or
• Termination of Domestic partnership submitted to
Divorce or Domestic Partnership Termination
the Secretary of State's Office
• New address - Please provide your new address to
Move
your agency's personnel office
• Birth Certificate/Adoption Paperwork
Birth/Adoption
• Health Benefits Plan Enrollment Form (HBD-12)
Open Enrollment
SECTION D: Subscriber and Dependent Information
List yourself and other dependents and the actions you are requesting (add or delete). Use the relationship codes to
identify the type of dependents.
SECTION E: Enrollment
To enroll in a CalPERS health plan, you must review the information and check the box in part 16. To decline enrollment in
a CalPERS health plan, you must review the information and check the box in part 17. Sign and date the form in parts 18
and 19.
SECTIONS F & G: CalPERS Privacy Notices
Please review these important privacy notices.
SECTION H: Employer Use Only
Your agency's personnel office will complete this section.
More Information
You can obtain health benefits publications, required forms, and other information about your CalPERS health benefits
through our website at www.calpers.ca.gov or by calling CalPERS at 888 CalPERS (or 888-225-7377) .
HBD-12 Instructions (Rev 01/2018)
Page 1 of 1
Health Benefits Plan Enrollment for Active Employees (HBD-12) Instructions
Contact your agency's personnel office if you have questions about your health enrollment. To enroll or decline enrollment
in the CalPERS Health Program or to make changes to your health plan, you must submit an HBD-12 form to your Health
Benefits Officer (HBO). If you have more than five dependents, please complete another HBD-12 form. Your agency's
personnel office will retain your original HBD-12 form and supporting documentation or affidavits in your employee file and
will provide a copy to you.
SECTION A: Applicant Information
Enter your basic information as indicated. If you are using your work zip code for health eligibility, please include your work
zip code in part 8.
SECTIONS B & C: Type of Action and Type of Permitting Event
Select the the type of action and your permitting event. Below is a list of permitting events and required documentation. The
required documents in the table below are not inclusive; you may need to submit additional documentation upon your
HBO's request.
Permitting Event
Required Documentation
New Employee
• Health Benefits Plan Enrollment Form (HBD-12)
New Contracting Agency
• Health Benefits Plan Enrollment Form (HBD-12)
• Marriage Certificate or
• Declaration of Domestic Partnership from the
Marriage or Domestic Partnership
Secretary of State's Office
Delete Dependent Due to Death
• Death Certificate
• Divorce Decree or
• Termination of Domestic partnership submitted to
Divorce or Domestic Partnership Termination
the Secretary of State's Office
• New address - Please provide your new address to
Move
your agency's personnel office
• Birth Certificate/Adoption Paperwork
Birth/Adoption
• Health Benefits Plan Enrollment Form (HBD-12)
Open Enrollment
SECTION D: Subscriber and Dependent Information
List yourself and other dependents and the actions you are requesting (add or delete). Use the relationship codes to
identify the type of dependents.
SECTION E: Enrollment
To enroll in a CalPERS health plan, you must review the information and check the box in part 16. To decline enrollment in
a CalPERS health plan, you must review the information and check the box in part 17. Sign and date the form in parts 18
and 19.
SECTIONS F & G: CalPERS Privacy Notices
Please review these important privacy notices.
SECTION H: Employer Use Only
Your agency's personnel office will complete this section.
More Information
You can obtain health benefits publications, required forms, and other information about your CalPERS health benefits
through our website at www.calpers.ca.gov or by calling CalPERS at 888 CalPERS (or 888-225-7377) .
HBD-12 Instructions (Rev 01/2018)
Page 1 of 1