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OEBB Members

Enrollment and Change Forms

Use this form to initially enroll in benefits effective October 1, 2014 or later

       ●   2013-14 New Hire Enrollment Form - (revised 2/20/2014)

Use this form to initially enroll in benefits effective before October 1, 2014.

       ●   Midyear Change Form with Medical Home - revised 8/5/2014

       ●   Additional Dependents Form - attach this to other enrollment/change forms if you need to list additional dependents
       ●   Long Term Care Enrollment Form ​

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


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
​       ●   Submit your appeal online (no paper or ink needed!)  Review the OEBB Appeal Policy
       ●   Paper Appeal Form (print, complete, then mail or fax)      Review the OEBB Appeal Policy
       ●   Public Comment Notice Form

       ●   Public Records Request Form - All public records requests must be submitted to OHA. All policies, fees, forms, and instructions related to this process can be found on the Request Records page of the OHA website.
Reimburse your unpaid claims (no guarantee of payment)
       ●   Reimbursement Form - Kaiser Permanente
       ●   Reimbursement Forms - Moda Health/ODS medical, dental, vision and pharmacy
Transition of Care
       ●   Transition of Care Request Form - Moda Health/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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Employing Entity


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

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OEBB-Administered Self-Pay Early Retirees

These forms are only for those retirees who pay their full monthly premium directly to OEBB. If you are a retiree who receives a monthly stipend or contribution from your former employer to help offset the cost of your insurance premiums, or if you currently pay your former employer your full insurance premiums, you should use the forms in the "OEBB Members" section of this webpage.

​Form Name PDF Format (print, complete by hand and submit to OEBB)​ ​Online Form (complete online and submit to OEBB electronically - no printing necessary)
​Self-Pay Early Retiree ACH Debit Authorization Form ​Printable form N/A - This form must be printed and submitted hard copy
Self-Pay Early Retiree​ Change of Address Form Printable form Online Form
​Self-Pay Early Retiree Terminate Benefits Form Printable form Online Form


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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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