Health Benefit Forms
To enroll in the Kaiser or Kaiser Senior Advantage Plan*, please use:
2024 Medical Plan Enrollment Form (Kaiser) for 2024 plan year
To enroll in Anthem Blue Cross HMO or PPO, UnitedHealthcare, SCAN, or Anthem Blue Cross Medicare Preferred (PPO)*, please use:
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 in either the DeltaCare USA HMO or the Delta Dental PPO dental plan:
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.
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.
2024 Medical/Dental Plan Cancellation Form for 2024 plan year
Senior Enrollment Forms
2024 Kaiser Senior Advantage HMO form
2024 Anthem Blue Cross Medicare Preferred (PPO)(for those with Medicare Parts A & B)
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)
2024 UnitedHealthcare Medicare Advantage HMO - Southern California