Forms to Submit for Enrollment

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During your retirement counseling session, LACERS Staff will provide the necessary forms for your Health Plan Enrollment. This section will help you determine which forms to submit to enroll in the LACERS Health Plan of your choice, add or delete dependents from your plan, or cancel your coverage.

Enroll into a New Medical Plan

Medical Plan enrollment includes vision coverage.

1. Which Medical Plan will you select?

To enroll into the Kaiser or Kaiser Senior Advantage Plan, submit LACERS Medical Plan Enrollment Form (Kaiser).

To enroll into Anthem Blue Cross HMO or PPO, UnitedHealthCare, SCAN, or Anthem Blue Cross Life & Health Medicare Supplement Plans, submit LACERS Medical Plan Enrollment Form (Non-Kaiser). 

2. Are you Covering any Dependents?

Members who will be covering one or more dependents on their Medical Plan will also need to submit:

3. Do you or your dependent have Medicare?

For Members or dependents who are enrolled in Medicare, please contact LACERS to obtain enrollment or disenrollment forms for the following Medicare plans:

  • Anthem Blue Cross Life and Health
  • Kaiser Permanente Senior Advantage
  • UnitedHealthCare Medicare Advantage
  • SCAN Medicare Advantage

Enroll into a New Dental Plan

1. Which Dental Plan will you select?

To enroll into either the DeltaCare USA HMO or the Delta Dental PPO dental plan submit LACERS Dental Plan Enrollment form:

2. Are you Covering any Dependents?

Members who will be covering one or more dependents on their Dental Plan will also need to submit:

Add or Delete Dependents from Your Current Plan

1. Which Health Plan(s) will add/delete your dependent?

To add or delete a dependent from your current Medical, Dental, or both plans, submit LACERS Family Account Change form:

Members who are adding one or more dependents on their Medical or Dental Plan will also need to submit:

2. Does your dependent have Medicare?

For dependents who are enrolled in Medicare, please contact LACERS to obtain enrollment forms for the following Medicare plans:

  • Anthem Blue Cross Life and Health
  • Kaiser Permanente Senior Advantage
  • UnitedHealthCare Medicare Advantage
  • SCAN Medicare Advantage

Cancel your Medical or Dental Plan

Members may cancel their LACERS Health Plans at any time. Coverage will be terminated on the first day of the month after the completed form is received.

1. Which Health Plan(s) will you be cancelling?

Submit LACERS Medical/Dental Plan Cancellation Form: 

2. Are you or your dependents enrolled in Medicare?

For Members or dependents who are enrolled in Medicare, please contact LACERS to obtain disenrollment request forms for the following Medicare plans:

  • Anthem Blue Cross Life and Health
  • Kaiser Permanente Senior Advantage
  • UnitedHealthCare Medicare Advantage
  • SCAN Medicare Advantage

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