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Oregon Educators Benefit Board

Forms

OEBB Members


Enrollment and Change Forms
       ●   2012-13 New Hire Enrollment Form - revised 09/19/2012​
       ●   Midyear Change Form - revised 9/21/2012
       ●   Open Enrollment Change Form - revised 8/16/2012 
       ●   Long Term Care Enrollment Form ​

       ●   Are you eligible for OEBB benefits through HB 2557? Click Here. 

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Optional Insurance
       ●   Beneficiary Designation Form 
       ●   Medical History Statement for life & disability insurance (online)
       ●   Medical History Statement for long term care insurance (pdf)
       ●   Terminate Long Term Care Insurance Form 
       ●   Click here for more forms and information on life & disability insurance
       ●   Click here for more forms and information on long term care insurance
Covering Others
       ●   Affidavit of Domestic Partnership - revised 9/19/2012
       ●   Termination of Domestic Partnership Form 
Appeal, Public Comment, Public Records
       ●   Appeal Form      Review the OEBB Appeal Policy
       ●   Public Comment Notice Form

       ●   Public Records Request Form
Reimburse your unpaid claims (no guarantee of payment)
       ●   Reimbursement Form - Kaiser Permanente
       ●   Reimbursement Forms - ODS medical, dental, vision and pharmacy
Transition of Care
       ●   Transition of Care Request Form - ODS
Weight Watchers
       ●   Online subscription Proof of Participation Form
                    Microsoft Word format (computer fillable form)
                    Adobe pdf format (print blank form and complete manually)
 

If you have questions, please call OEBB at 888-469-6322
Need more help? Click Here. 

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Educational Entity

 

 If you have questions, please call OEBB at 888-469-6322
 Need more help? Click Here. 
 

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General Public

       ●   Public Comment Notice Form

       ●   Public Records Request 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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