The retiree's sections are Retiree Information, Enrollment Election and Dependent Information; the last section is For Employing Agency Use Only.
Open enrollment: Not for open enrollment use.
Plan year: A plan year runs from January 1 of any year through December 31 of the same calendar year.
Dependents: Only eligible dependents may be enrolled into this plan with the retiree.
Dependent Types: S - Spouse, DP - Domestic Partner, C - Natural/Adopted Child, SC - Step Child, DPC -Domestic Partner Child, PCR - Parent Child Relationship
Copy: 1 copy to Vendor, 1 copy to Employing Agency, 1 copy to Retiree
| Question | Answer |
|---|---|
| Form Name | Form CalHR 695 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 69 |
| Avg. time to fill out | 12 min |
| Edition | 09/2021 |
| Issuing agency | California Department of Human Resources |
| Where to send | VSP-Attn: Client Administrative Services, MS 229 PO Box 997100 Sacramento, CA 95899-7100 |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | CalHR 695, CalHR695, CAL HR 695, California CalHR 695, Retiree Vision Plan Enrollment |
| Official source | Form CalHR 695 (Rev 09/2021), California Department of Human Resources |
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