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OEBB Forms

Below is a list of forms used for OEBB benefits and processes, including those used by OEBB members, OEBB-participating entities, and the general public.

You can sort and filter the list by hovering over the Category, Plan Year or Name header and selecting from the options listed.

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Notes
2015-16HB2557-ACH-Form-2015-16
2015-16HB2557-Enrollment-Form-2015-16
Appeals2014-15Appeal-Form
Print, complete, then mail or fax
Claims Reimbursement2014-15Reimbursement-Form-Kaiser-Permanente
Covering Others2014-15Affidavit-of-Domestic-Partnership
Revised 9/19/2012
Covering Others2014-15Termination-of-Domestic-Partnership-Form
Employing Entities2014-15Authorization-Agreement-Employer-ACH-Payments
Employing Entities2014-15Comparability-Assessment-Application
Revised May 2012
Employing EntitiesDEV-Review-Plan-Third-Party-Vendor-Approval-Form
Employing Entities2014-15Division-60-Social-Security-Numbers-Consent-Form
Employing Entities2014-15Electronic-Funds-Transfer-Brochure
Employing Entities2014-15Local-Government-Letter-of-Interest-Form
Employing Entities2014-15MyOEBB-Rules-Selection-Form
Employing Entities2014-15MyOEBB-Security-Access-Termination-Form
Employing Entities2014-15MyOEBB-User-Access-Form
Employing Entities2014-15New-Hire-Enrollment-Customizable-Form
Customizable Word format
Employing Entities2014-15OEBB-Plan-Selection-Criteria-Checklist
Employing Entities2014-15Summary-Enrollment-Premium-Rates
Revised May 2012
Enrollment and Change2014-15ACH-Debit-Authorization-Form
Enrollment and Change2014-15Additional-Dependents-Form
Attach this to other enrollment/change forms if you need to list additional dependents.
Enrollment and Change2014-15HB2557-Member-Enrollment-Form-2014-15
Enrollment and Change2014-15HB2557-Midyear-Change-Form
Enrollment and Change2014-15Midyear-Change-Form-2014-15
(revised 8/5/2014)
Enrollment and Change2015-16Midyear-Change-Form-2015-16
(revised 7/28/2015)
Enrollment and Change2014-15Midyear-Change-for-Tobacco-Use
Enrollment and Change2014-15New-Hire-Enrollment-Form-2014-15
Use this form to initially enroll in benefits effective October 1, 2014 or later.
Enrollment and Change2015-16New-Hire-Enrollment-Form-2015-16
Use this form to initially enroll in benefits effective October 1, 2015 or later.
Enrollment and Change2015-16Open-Enrollment-Form-2015-16
This form is for the 2015 open enrollment period.
OEBB Fitness Rewards2015-16OFR-Registration-Form
revised 8-18-15, gray lightened to improve fax quality
OEBB Fitness Rewards2015-16OFR-Reimb-Form
revised 8-18-15, gray lightened to improve fax quality
Optional Insurance2014-15Beneficiary-Designation-Form
Optional Insurance2014-15Medical-History-Statement
For long term care insurance.
Optional Insurance2014-15Terminate-Long-Term-Care-Insurance-Form
Public Comment2014-15Public-Comment-Notice-Form
Public Records2014-15Public-Records-Request-Form
Self-Pay Early Retiree2014-15Self-Pay-Early-Retiree-ACH-Debit-Authorization-Form
This form must be printed and submitted hard copy
Self-Pay Early Retiree2014-15Self-Pay-Early-Retiree-ACH-Debit-Form
Self-Pay Early Retiree2014-15Self-Pay-Early-Retiree-Agreement
Self-Pay Early Retiree2014-15Self-Pay-Early-Retiree-Change-of-Address-Form
Printable form
Self-Pay Early Retiree2014-15Self-Pay-Early-Retiree-Enrollment-Form
Self-Pay Early Retiree2015-16Self-Pay-Early-Retiree-Midyear-Change-Form
Self-Pay Early Retiree2015-16Self-Pay-Early-Retiree-Open-Enrollment-Form
Use this form for the 2015 open enrollment period.
Self-Pay Early Retiree2014-15Self-Pay-Early-Retiree-Sample-Cover-Letter
Self-Pay Early Retiree2014-15Self-Pay-Early-Retiree-Sample-Cover-Letter-2
Self-Pay Early Retiree2014-15Self-Pay-Early-Retiree-Sample-Welcome-Letter-No-Form
Self-Pay Early Retiree2014-15Self-Pay-Early-Retiree-Sample-Welcome-Letter-With-Form
Self-Pay Early Retiree2014-15Self-Pay-Early-Retiree-Terminate-Benefits-Form
Printable form
Transition of care2014-15Transition-of-Care-Request-Form-Moda-Health
Weight Watchers2014-15Weight-Watchers-Gateway
Enrollment and renewal form
Weight Watchers2014-15Weight-Watchers-Proof-of-Participation-Form
Microsoft Word format computer fillable form
Weight Watchers2014-15Weight-Watchers-Proof-of-Participation-Form
Adobe PDF format, print blank form and complete manually
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Links to external forms

  
  
  
Notes
Optional Insurance2014-15Forms and information on life and disability insurance
The Standard
Optional Insurance2014-15Forms and information on long term care insurance
Unum
Enrollment and Change2014-15Long Term Care Enrollment Form
Optional Insurance2014-15Medical History Statement for life and disability insurance
Online form
Claims Reimbursement2014-15Reimbursement Forms Moda Health
Medical, dental, vision and pharmacy
Self-Pay Early Retiree2014-15Self-Pay Early Retiree Terminate Benefits Form
Online Form
Self-Pay Early Retiree2014-15Self-Pay Early Retiree​ Change of Address Form
Online Form
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Can't find it?

Here's where you can find some other documents you may need:

Medicare Creditable and Noncreditable Coverage Notices

Please visit our Required Notices page.


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