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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
Appeals2014-2015Appeal Form
Print, complete, then mail or fax
Claims Reimbursement2014-2015Reimbursement Form Kaiser Permanente
Covering Others2014-2015Affidavit of Domestic Partnership
Revised 9/19/2012
Covering Others2014-2015Termination of Domestic Partnership Form
Employing Entities2014-2015Authorization Agreement Employer ACH Payments
Employing Entities2014-2015Comparability Assessment Application
Revised May 2012
Employing EntitiesDEV Review Plan Third Party Vendor Approval Form
Employing Entities2014-2015Division 60 Social Security Numbers Consent Form
Employing Entities2014-2015Electronic Funds Transfer Brochure
Employing Entities2014-2015Local Government Letter of Interest Form
Employing Entities2014-2015MyOEBB Rules Selection Form
Employing Entities2014-2015MyOEBB-Security-Access-Termination-Form
Employing Entities2014-2015New Hire Enrollment Customizable Form
Customizable Word format
Employing Entities2014-2015OEBB Plan Selection Criteria Checklist
Employing Entities2014-2015Summary Enrollment Premium Rates
Revised May 2012
Employing Entities2014-2015User Access Form
Enrollment and Change2014-2015ACH Debit Authorization Form
Enrollment and Change2014-2015Additional Dependents Form
Attach this to other enrollment/change forms if you need to list additional dependents.
Enrollment and Change2014-2015HB 2557 Member Enrollment Form
Enrollment and Change2014-2015HB2557 Midyear Change Form
Enrollment and Change2014-2015Midyear Change for Tobacco Use
Enrollment and Change2014-2015Midyear Change Form with Medical Home
(revised 8/5/2014)
Enrollment and Change2015-2016Midyear Change Form
(revised 7/28/2015)
Enrollment and Change2014-2015New Hire Enrollment Form 2014-15
Use this form to initially enroll in benefits effective October 1, 2014 or later.
Enrollment and Change2015-2016New Hire Enrollment Form 2015-16
Use this form to initially enroll in benefits effective October 1, 2015 or later.
Enrollment and Change2015-2016Open Enrollment Form 2015-16
This form is for the 2015 open enrollment period.
Optional Insurance2014-2015Beneficiary Designation Form
Optional Insurance2014-2015Medical History Statement
For long term care insurance.
Optional Insurance2014-2015Terminate Long Term Care Insurance Form
Public Comment2014-2015Public Comment Notice Form
Public Records2014-2015Public Records Request Form
Self-Pay Early Retiree2015-2016Self-Pay Early Retiree Midyear Change Form
Self-Pay Early Retiree2015-2016Self-Pay Early Retiree Open Enrollment Form
Use this form for the 2015 open enrollment period.
Self-Pay Early Retiree2014-2015Self-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 Retiree2014-2015Self-Pay-Early-Retiree-Change-of-Address-Form
Printable form
Self-Pay Early Retiree2014-15Self-Pay-Early-Retiree-Enrollment-Form
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 Retiree2014-2015Self-Pay-Early-Retiree-Terminate-Benefits-Form
Printable form
Transition of care2014-2015Transition of Care Request Form Moda Health
Weight Watchers2014-2015Weight Watchers Gateway
Enrollment and renewal form
Weight Watchers2014-2015Weight Watchers Proof of Participation Form
Microsoft Word format computer fillable form
Weight Watchers2014-2015Weight Watchers Proof of Participation Form
Adobe PDF format, print blank form and complete manually
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Links to external forms

  
  
  
Notes
Optional Insurance2014-2015Forms and information on life and disability insurance
The Standard
Optional Insurance2014-2015Forms and information on long term care insurance
Unum
Enrollment and Change2014-2015Long Term Care Enrollment Form
Optional Insurance2014-2015Medical History Statement for life and disability insurance
Online form
Claims Reimbursement2014-2015Reimbursement Forms Moda Health
Medical, dental, vision and pharmacy
Self-Pay Early Retiree2014-2015Self-Pay Early Retiree Terminate Benefits Form
Online Form
Self-Pay Early Retiree2014-2015Self-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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