Health Benefit Forms*

2021 Open Enrollment Overview
2021 Medical/Dental Family Account Change Form
2021 Medical Plan Enrollment Form (Non-Kaiser)
2021 Medical Plan Enrollment Form (Kaiser)
2021 Dental Plan Enrollment Form
Certification of Dependent or Survivor Status for Health Coverage
Medicare Information Acknowledgement Form

*Contact LACERS if you need enrollment forms for the following plans:

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