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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.

Print, complete, then mail or fax
Claims ReimbursementReimbursement-Form-Kaiser-Permanente
Covering OthersAffidavit-of-Domestic-Partnership
Revised 9/19/2012
Covering OthersTermination-of-Domestic-Partnership-Form
Employing EntitiesAuthorization-Agreement-Employer-ACH-Payments
Employing EntitiesComparability-Assessment-Application
Revised May 2012
Employing EntitiesDEV-Review-Plan-Third-Party-Vendor-Approval-Form
Revised October 19, 2015
Employing EntitiesDivision-60-Social-Security-Numbers-Consent-Form
Employing EntitiesElectronic-Funds-Transfer-Brochure
Employing EntitiesLocal-Government-Letter-of-Interest-Form
Employing EntitiesMyOEBB-Rules-Selection-Form
Employing EntitiesMyOEBB-Security-Access-Termination-Form
Employing EntitiesMyOEBB-User-Access-Form
Employing EntitiesNew-Hire-Enrollment-Customizable-Form
Customizable Word format
Employing EntitiesOEBB-Plan-Selection-Criteria-Checklist
Employing EntitiesSummary-Enrollment-Premium-Rates
Revised May 2012
Enrollment and Change2015-16-Enrollment-Change-Form-Med-Vis-Only
This is a special form created for and sent directly to members who enrolled in both Kaiser Medical Plan 3 and Kaiser Vision Plan 5 for 2015-16. Only valid through October 16, 2015.
Enrollment and ChangeACH-Debit-Authorization-Form
Enrollment and ChangeAdditional-Dependents-Form
Attach this to other enrollment/change forms if you need to list additional dependents.
Enrollment and ChangeMidyear-Change-Form-2015-16
(revised 11/4/2015)
Enrollment and ChangeMidyear-Change-for-Tobacco-Use
Enrollment and ChangeNew-Hire-Enrollment-Form-2014-15
Use this form to initially enroll in benefits effective October 1, 2014 or later.
Enrollment and ChangeNew-Hire-Enrollment-Form-2015-16
Use this form to initially enroll in benefits effective October 1, 2015 or later. (revised 11-4-2015)
OEBB Fitness RewardsOFR-Registration-Form
revised 10-26-15, clarified language around attaching voided check; revised 11-5-15 removed shading for legibility when faxing
OEBB Fitness RewardsOFR-Reimb-Form
revised 8-18-15, gray lightened to improve fax quality
Optional InsuranceBeneficiary-Designation-Form
Optional InsuranceMedical-History-Statement
For long term care insurance.
Optional InsuranceTerminate-Long-Term-Care-Insurance-Form
Public CommentPublic-Comment-Notice-Form
Public RecordsPublic-Records-Request-Form
Self-Pay Early RetireeSelf-Pay-Early-Retiree-ACH-Debit-Authorization-Form
This form must be printed and submitted hard copy
Self-Pay Early RetireeSelf-Pay-Early-Retiree-ACH-Debit-Form
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Agreement
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Change-of-Address-Form
Printable form
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Enrollment-Form
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Midyear-Change-Form
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Sample-Cover-Letter
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Sample-Cover-Letter-2
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Sample-Welcome-Letter-No-Form
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Sample-Welcome-Letter-With-Form
Self-Pay Early RetireeSelf-Pay-Early-Retiree-Terminate-Benefits-Form
Printable form
Transition of careTransition-of-Care-Request-Form-Moda-Health
Weight WatchersWeight-Watchers-Gateway
Enrollment and renewal form
Weight WatchersWeight-Watchers-Proof-of-Participation-Form
Microsoft Word format computer fillable form
Weight WatchersWeight-Watchers-Proof-of-Participation-Form
Adobe PDF format, print blank form and complete manually

Links to external forms

Optional InsuranceForms and information on life and disability insurance
The Standard
Optional InsuranceForms and information on long term care insurance
Enrollment and ChangeLong Term Care Enrollment Form
Optional InsuranceMedical History Statement for life and disability insurance
Online form
Claims ReimbursementReimbursement 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

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.