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Forms

OEBB Form​s

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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Enrollment and Change2015-16-Enrollment-Change-Form-Med-Vis-Only2015-16 Enrollment Change Form (Med-Vis Only)
Enrollment and ChangeACH-Debit-Authorization-FormACH Debit Authorization Form​
Enrollment and ChangeAdditional-Dependents-FormAdditional Dependents Form
Covering OthersAffidavit-of-Domestic-PartnershipAffidavit of Domestic Partnership
AppealsAppeal-FormPaper Appeal Form
Employing EntitiesAuthorization-Agreement-Employer-ACH-PaymentsAuthorization Agreement for Employer ACH Payments
Optional InsuranceBeneficiary-Designation-FormBeneficiary Designation Form
Employing EntitiesComparability-Assessment-ApplicationComparability Assessment Application
Employing EntitiesDEV-Review-Plan-Third-Party-Vendor-Approval-FormDEV Review Plan Third Party Vendor Approval Form
Employing EntitiesDiv 60 Entity SSN Consent FormDivision 60 Social Security Numbers Consent Form
Employing EntitiesElectronic-Funds-Transfer-BrochureElectronic Funds Transfer Brochure
HB2557HB2557-ACH-Form-2015-16HB2557 ACH Form 2015-16
HB2557HB2557-Enrollment-Form-2015-16HB2557 Enrollment Form 2015-16
HB2557HB2557-Midyear-Change-FormHB2557 Midyear Change Form
Employing EntitiesLocal-Government-Letter-of-Interest-FormLocal Government Letter of Interest Form
Optional InsuranceMedical-History-StatementMedical History Statement for Unum long term care insurance
Enrollment and ChangeMidyear-Change-Form-2015-16Midyear Change Form 2015-16
Enrollment and ChangeMidyear-Change-for-Tobacco-UseMidyear Change for Tobacco Use
Employing EntitiesMyOEBB User Access FormUse this form to grant or terminate access to the MyOEBB system
Employing EntitiesMyOEBB-Rules-Selection-FormMyOEBB Rules Selection Form
Employing EntitiesNew-Hire-Enrollment-Customizable-FormCustomizable Enrollment Form
Enrollment and ChangeNew-Hire-Enrollment-Form-2015-16New Hire Enrollment Form 2015-16
Employing EntitiesOEBB-Plan-Selection-Criteria-ChecklistOEBB Plan Selection Criteria Checklist
OEBB Fitness RewardsOFR-Registration-FormOEBB Fitness Rewards Registration Form
OEBB Fitness RewardsOFR-Reimb-FormOEBB-Fitness-Rewards-Reimbursement-Request-Form
Public CommentPublic-Comment-Notice-FormPublic Comment Notice Form
Public RecordsPublic-Records-Request-FormPublic Records Request Form
Claims ReimbursementReimbursement-Form-Kaiser-PermanenteReimbursement Form Kaiser Permanente
Self-Pay Early RetireeSelf-Pay-Early-Retiree-ACH-Debit-Authorization-FormSelf-Pay Early Retiree ACH Debit Authorization Form
Self-Pay Early RetireeSelf-Pay-Early-Retiree-AgreementSelf-Pay-Early-Retiree-Agreement
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Change-of-Address-FormSelf-Pay Early Retiree​ Change of Address Form
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Enrollment-FormSelf-Pay Early Retiree Enrollment Form
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Midyear-Change-Form
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Sample-Cover-LetterSelf-Pay Early Retiree Sample Cover Letter
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Sample-Cover-Letter-2Self-Pay Early Retiree Sample Cover Letter 2
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Sample-Welcome-Letter-No-FormOEBB Cover Letter for Self-Pay to Self-Pay Early Retirees
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Sample-Welcome-Letter-With-FormOEBB Cover Letter for "Active to Self-Pay" or "Losing Stipend" Early Retirees
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Terminate-Benefits-FormSelf-Pay Early Retiree Terminate Benefits Form
Employing EntitiesSummary-Enrollment-Premium-RatesEnrollment and Premium Rates May 2012
Optional InsuranceTerminate-Long-Term-Care-Insurance-FormTerminate Long Term Care Insurance Form
Covering OthersTermination-of-Domestic-Partnership-FormTermination of Domestic Partnership Form
Transition of careTransition-of-Care-Request-Form-Moda-HealthTransition of Care Request Form Moda Health
Weight WatchersWeight-Watchers-GatewayWeight Watchers Gateway
Weight WatchersWeight-Watchers-Proof-of-Participation-FormWeight Watchers Proof of Participation Form
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Links to external forms

  
  
Notes
Optional InsuranceForms and information on life and disability insurance
The Standard
Optional InsuranceForms and information on long term care insurance
Unum
Optional InsuranceMedical History Statement for life and disability insurance
The Standard - Online form
Claims ReimbursementModa Health Reimbursement Forms
Moda Health - Medical, dental, vision and pharmacy
Self-Pay Early RetireeSelf-Pay Early Retiree Terminate Benefits Form
Online Form
Self-Pay Early RetireeSelf-Pay Early Retiree​ Change of Address Form
Online Form
Enrollment and ChangeUnum Long Term Care Enrollment Form
Unum
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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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