Health Benefit Forms*

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

2022 Medical/Dental Plan Cancellation Form
2022 Dental Plan Enrollment Form
2022 Open Enrollment Overview

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

*Additional forms are needed if enrolling in one of LACERS’ Medicare plans.  Contact LACERS to get these forms or they are available at the links below for the following plans:

2021 Kaiser Permanente Senior Advantage HMO (the 2021 Kaiser form is valid to use for 2022 enrollment until further notice)
2022 Anthem Blue Cross Medicare Preferred (PPO) (for those with Medicare Parts A & B; enrollment form is within packet, near the end)
2022 UnitedHealthcare Medicare Advantage HMO – Southern California (Please contact LACERS for the enrollment forms specific to UnitedHealthcare Northern California, Nevada, or Arizona)
2022 SCAN Health Plan Medicare Advantage HMO
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)

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