Health Benefit Forms*

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

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

2022 Medical Plan Enrollment Form (Kaiser) for 2022 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

2022 Medical Plan Enrollment Form (Non-Kaiser) for 2022 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

2022 Dental Plan Enrollment Form for 2022 plan year

Add or Delete Dependents* from Your Medical and/or Dental Plan

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

2022 Medical/Dental Plan Family Account Change Form for 2022 plan year

Cancel/Disenroll your Medical or Dental Plan*

2023 Medical/Dental Plan Cancellation Form for 2023 plan year

2022 Medical/Dental Plan Cancellation Form for 2022 plan year

*Additional forms are needed if enrolling/disenrolling in one of LACERS’ Medicare plans. The senior forms for LACERS’ Medicare plans for the 2023 plan year are not yet available but will be posted when available. Please contact LACERS for 2023 plan year senior forms.

2022 Senior Enrollment Forms

2022 Kaiser Senior Advantage HMO form (the 2022 Kaiser form is valid for CALIFORNIA REGION ONLY)
2022 Anthem Blue Cross Medicare Preferred (PPO) (for those with Medicare Parts A & B; enrollment form is within packet, near the end)
2022 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)
2022 UnitedHealthcare Medicare Advantage HMO – Southern California (contact LACERS for enrollment forms specific to UnitedHealthcare Northern California, Nevada, or Arizona)
2022 SCAN Health Plan Medicare Advantage HMO