Forms

To enroll into the Kaiser or Kaiser Senior Advantage Plan*, please use: 

2023 Medical Plan Enrollment Form (Kaiser) for 2023 plan year

2024 Medical Plan Enrollment Form (Kaiser) for 2024 plan year

To enroll into Anthem Blue Cross HMO or PPO, UnitedHealthcare, SCAN, or Anthem Blue Cross Medicare Preferred (PPO)*, please use:

2023 Medical Plan Enrollment Form (Non-Kaiser) for 2023 plan year

2024 Medical Plan Enrollment Form (Non-Kaiser) for 2024 plan year

Covering dependents (medical and/or dental)? Complete and submit Certification of Dependent or Survivor Status for Health Coverage with:

• A copy of your certified marriage Certificate or Proof of Domestic Partnership
• A copy of your child’s birth certificate
• Proof of your child’s disability, if applicable

Retired Members and Survivors and dependents with Medicare Complete and submit the Medicare Information Acknowledgement Form in addition to senior forms*.

To enroll into either the DeltaCare USA HMO or the Delta Dental PPO dental plan:

2023 Dental Plan Enrollment Form for 2023 plan year

2024 Dental Plan Enrollment Form for 2024 plan year

Add or Delete Dependents* from Your Medical and/or Dental Plan - Forms are required to be submitted by the 10th of the month to be effective the 1st of the following month. If enrolled in Medicare Parts A&B or Part B only, please contact Health at LACERS.Health@lacers.org for the required form. If adding dependent(s), please read the Health Benefits Guide or Health Benefits Guide Supplement (if applicable) for the cost of adding dependent(s), and see above for the additional required forms.

2023 Medical/Dental Plan Family Account Change Form for 2023 plan year

2024 Medical/Dental Plan Family Account Change Form for 2024 plan year

Cancel/Disenroll your Medical or Dental Plan* - Forms are required to be submitted by the 10th of the month to be effective the 1st of the following month. If enrolled in Medicare Parts A&B or Part B only, please contact Health at LACERS.Health@lacers.org for the required form. If adding dependent(s), please read the Health Benefits Guide or Health Benefits Guide Supplement (if applicable) for the cost of adding dependent(s), and see above for the additional required forms.

2023 Medical/Dental Plan Cancellation Form for 2023 plan year

2024 Medical/Dental Plan Cancellation Form for 2024 plan year

Senior Enrollment Forms

2023 Kaiser Senior Advantage HMO form 

2024 Kaiser Senior Advantage HMO form

2023 Anthem Blue Cross Medicare Preferred (PPO)(for those with Medicare Parts A & B; enrollment form is within packet, near the end)

2024 Anthem Blue Cross Medicare Preferred (PPO)(for those with Medicare Parts A & B)

2023 Anthem Blue Cross Medicare Prescription Enrollment(for those with Medicare Part B ONLY, enrolling in the Anthem Medicare PPO or Anthem HMO; enrollment form within packet)

2024 Anthem Blue Cross Medicare Prescription Enrollment (for those with Medicare Part B ONLY, enrolling in the Anthem Medicare PPO, Anthem HMO, or for those with Medicare Parts A & B enrolling in the Anthem Life & Health Medicare Supplemental Plan)

2023 UnitedHealthcare Medicare Advantage HMO – Southern California(contact LACERS for enrollment forms specific to UnitedHealthcare Northern California, Nevada, or Arizona)

2024 UnitedHealthcare Medicare Advantage HMO - Southern California

2023 SCAN Health Plan Medicare Advantage HMO

2024 SCAN Health Plan Medicare Advantage HMO