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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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Employing Entities2016-17-New-Hire-Enrollment-Customizable-FormCustomizable Enrollment Form
Employing Entities2016-17-Open-Enrollment-Customizable-FormCustomizable Enrollment Form
Self-Pay Early RetireeActive-Employee-to-SPERS-Enrollment-Form2016-17 Active Employee to SPERS Enrollment Form
Covering OthersAffidavit-of-Domestic-PartnershipAffidavit of Domestic Partnership
AppealsAppeal-FormAppeal Form
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-SSN-Consent-FormNewDivision 60 SSN Consent Form
Employing EntitiesElectronic-Funds-Transfer-MemoNewElectronic Funds Transfer Memo
Employing EntitiesEmployer-ACH-AuthorizationAuthorization Agreement for Employer ACH Payments
OEBB Fitness RewardsFitness-Rewards-RegistrationFitness Rewards Registration
OEBB Fitness RewardsFitness-Rewards-ReimbursementFitness Rewards Reimbursement
HB2557HB2557-ACH-AuthorizationHB2557 ACH Authorization
HB2557HB2557-Enrollment-Form2016-17 HB2557 Enrollment Form
HB2557HB2557-Midyear-Change-Form2016-17 HB2557 Midyear Change Form
Employing EntitiesLocal-Gov-Notice-of-InterestNewLocal Government Notice of Interest
Optional InsuranceMedical-History-StatementMedical History Statement for Unum long term care insurance
Enrollment and ChangeMidyear-Change-Form2016-17 Midyear Change Form
Employing EntitiesMyOEBB User Access FormUse this form to grant or terminate access to the MyOEBB system
Employing EntitiesMyOEBB-Rules-Selection-FormMyOEBB Rules Selection Form
Enrollment and ChangeNew-Member-Enrollment-Form2016-17 New Member Enrollment Form
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
Enrollment and ChangeOpen-Enrollment-Form2016-17 Open Enrollment 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-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-Form
Self-Pay Early RetireeSPERS-ACH-AuthorizationSPERS ACH Authorization
Self-Pay Early RetireeSPERS-AgreementSelf-Pay Early Retiree Agreement
Self-Pay Early RetireeSPERS-Change-of-AddressSPERS Change of Address
Self-Pay Early RetireeSPERS-Dental-Only-Enrollment-Form2016-17 SPERS Dental Only Enrollment Form
Self-Pay Early RetireeSPERS-Midyear-Change-Form2016-17 SPERS Dental Only Enrollment Form
Self-Pay Early RetireeSPERS-Open-Enrollment-Form2016-17 SPERS Open Enrollment Form
Self-Pay Early RetireeSPERS-Open-Enrollment-Form-No-Optional-Plans2016-17 SPERS Open Enrollment Form - No Optional Plans
Self-Pay Early RetireeSPERS-Terminate-Benefits-FormSPERS Terminate Benefits Form
Employing EntitiesSummary-Enrollment-Premium-RatesEnrollment and Premium Rates May 2012
Optional InsuranceTerminate-LTC-InsuranceTerminate Long Term Care Insurance
Covering OthersTermination-of-Domestic-PartnershipTermination of Domestic Partnership
Enrollment and ChangeTobacco-Usage-Status-Change-FormTobacco Usage Status Change 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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