Form Hbd 12A PDF Details

Form Hbd 12A is used to request a change in the name of a minor child. This form can be used to either add or remove a parent's name from the child's birth certificate. In order to complete this form, you will need to provide some information about yourself and the child, as well as provide documentation supporting your request. Note that the State of California may require you to attend a hearing before it approves your request. For more information on Form Hbd 12A, including how to complete it correctly, please consult our guide below. We have outline all the steps necessary to ensure that your application is processed as quickly and efficiently as possible.

QuestionAnswer
Form NameForm Hbd 12A
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdeclaration health coverage, calpers hbd 12 form, calpers and forms and hbd 35, calpers declaration

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CMember Account Management Division P.O. Box 942715

Sacramento, CA 94229-2715 (888) CalPERS (or 888-225-7377)TTY (877) 249-7442

FAX (800) 959-6545

Declaration of Health Coverage: HBD-12A

(INSTRUCTIONS ON REVERSE)

EMPLOYEE INFORMATION

SOCIAL SECURITY NUMBER

NAME (FIRST)

(MIDDLE)

(LAST)

 

 

-

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART A

 

 

 

 

 

 

 

 

 

 

 

 

I elect to enroll myself and all eligible

 

 

 

 

 

 

 

dependents.

 

 

 

 

 

 

 

 

 

 

 

 

 

PART B-1

 

 

 

 

 

If you or your dependents lose health insurance

 

I elect to enroll myself. My eligible

coverage, you can enroll in the CalPERS Health Benefits

 

dependents have other health

Program. You must request enrollment within 60 days

 

insurance coverage.

from the date you lose coverage.

PART B-2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I elect to enroll myself and all eligible

If you do not request enrollment within 60 days, you or

 

dependents. I also have eligible

your dependents must wait at least 90 days or until the

 

dependents who have other health

next Open Enrollment Period before you can enroll in

 

insurance coverage.

 

the Program. Your effective date of coverage will be

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART C-1

 

 

 

 

 

the first of the month following the 90-day waiting

 

I decline enrollment for myself and

period or the Open Enrollment effective date.

 

my eligible dependents because we

 

 

 

 

 

 

 

have other health insurance coverage.

 

 

 

 

 

 

 

 

 

 

 

 

 

PART C-2

 

 

 

 

 

You can request enrollment for yourself and/or your

 

I decline enrollment for myself and/or

dependents at any time. You must wait at least 90 days

 

my eligible family members for

after you request enrollment or until the next Open

 

reasons other than having health

 

Enrollment Period before you can enroll in the Program.

 

insurance coverage.

 

Your effective date of coverage will be the first of the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

month following the 90 day waiting period or the Open

 

 

 

 

 

 

 

 

Enrollment effective date.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART B: If you are currently enrolled in the Health Benefits Program and you acquire new dependents or if a court orders health coverage for your dependents, you can add your new dependents. See your Health Benefits Officer or visit your personnel office for applicable time limits.

PART C: If you are not currently enrolled in the Health Benefits Program and you acquire new dependents as a result of marriage, birth, adoption, or placement for adoption, or if a court orders health coverage for your dependents, you can enroll yourself and dependents. See your Health Benefits Officer or visit your personnel office for applicable time limits.

Special rules apply to retirement and death. Please read the back of this form carefully.

Member’s Signature

Date Signed

Health Benefits Officer’s Signature

Rev 12/15

Original: Employee’s Personnel File

Copy: Employee

INSTRUCTIONS – DECLARATION OF HEALTH COVERAGE (HBD-12A)

Please contact your Health Benefits Officer if you have any questions regarding the HBD‐12A.

Employee

Complete with the appropriate employee information.

Information

 

 

 

 

Part A:

Mark this box if you are:

 

a)

Enrolling in the Health Benefits Program and have no dependents, or

 

b)

Enrolling yourself and ALL eligible dependents in the Health Benefits Program.

 

 

Part B-1:

Mark this box if you are:

 

a)

Enrolling yourself only, your dependents have other health insurance coverage, or

 

b)

Canceling your dependents’ coverage because they have other health insurance

 

 

coverage

Part B-2:

Mark this box if you are:

 

a)

Enrolling yourself and SOME of your dependents, your other dependents have health

 

 

insurance coverage, or

 

b)

Canceling coverage for some of your dependents because they have other health

 

 

insurance coverage.

 

 

Part C-1:

Mark this box if you are:

 

a)

Declining enrollment or canceling your health insurance coverage, you have no

 

 

dependents and you have other health coverage, or

 

b)

Declining enrollment or canceling your health insurance coverage for yourself and

 

 

eligible dependents and you have other health insurance coverage.

Part C-2:

Mark this box if you are:

a)

Declining enrollment or canceling your health insurance for reasons other than

 

 

 

having health insurance coverage and you have no dependents, or

 

b)

Declining enrollment or canceling your health insurance coverage for yourself and

 

 

eligible dependents for reasons other than having health insurance coverage.

 

 

 

IMPORTANT: It is your responsibility to notify your personnel office when there are any changes in your family situation. Changes include marriage, acquisition of a dependent child, divorce, legal separation, and death. Failure to notify your personnel office may result in adverse consequences.

Special rules to consider for retirement and death:

Retirees: you are eligible to enroll in a CalPERS health plan if you meet all of the criteria below:

Your retirement date is within 120 days of separation from employment

You are eligible for health benefits upon separation

You receive a monthly retirement allowance

You retire from the State, California State University (CSU), or an agency that currently contracts with CalPERS for health benefits

Survivor Death Benefit: your dependents may enroll in a CalPERS health plan as a survivor as long as they:

Are eligible for enrollment as a dependent on the date of death of a CalPERS retiree

Receive a monthly survivor check

Continue to qualify as an eligible family member

Dependents who are enrolled at the time of the employee or annuitant’s death and meet the eligibility requirements can continue the health enrollment as a survivor. Dependents who are not enrolled and meet the eligibility requirements may enroll in a health plan within 60 days of the employee or annuitant’s death, or during Open Enrollment.

The effective date of enrollment is the first day of the month following the date CalPERS receives the request. Exceptions may apply for certain contracting agency survivors who do not receive a monthly survivor check. Your survivor will need to contact your former employer for additional information.

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