Complete Sections A, B, and D for NEW or COBRA, Sections A, C, D for CANCEL, and Sections A, B, C, and D for CHANGE.
Enrolling: the employee authorizes deductions from salary or retirement allowance to cover their share of cost of enrollment.
Family members: when changing family member enrollment, list all family members currently enrolled, as well as family members to be added and/or deleted.
Action code: enter the action code A (add) and/or D (delete) besides the names of only those members to be added or deleted.
Copies: copies of the Dental Plan Enrollment Authorization are maintained in confidential files of the State Controller's Office for five years.
Section E: for agency or retirement system use only.
| Question | Answer |
|---|---|
| Form Name | Form STD 692 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 172 |
| Avg. time to fill out | 29 min |
| Edition | 4/2024 |
| Issuing agency | California Department of Human Resources |
| Where to send | Personnel/Payroll Office |
| Who signs | The employee or annuitant |
| Other names | STD 692, STD 692, STD692, Form STD 692, Dental Plan Enrollment Authorization, California dental plan enrollment form |
| Official source | Form STD 692 (Rev 4/2024), California Department of Human Resources |
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