Hbd 12 Form PDF Details

Fulfilling the requirements of the Hbd 12 form is a fine line to tread in ensuring personal data is handled with the highest level of integrity and privacy. CalPERS stands as a guardian to this commitment, abiding by the Information Practices Act of 1977 and the Federal Privacy Act of 1974, setting a framework that balances the need for information with the respect for personal privacy. This form, crucial for the administration of Board duties under various legislative acts, mandates the submission of certain pieces of information, including Social Security numbers. These details serve multiple administrative purposes, from enrollee identification to the resolution of member grievances with health plan carriers. Importantly, though submission is mandatory to facilitate the execution of CalPERS' functions regarding an individual's status, there's an emphasis on minimized disclosure, ensuring that the only eyes on sensitive information are those permitted by law. This circumspect approach extends to the use of Social Security numbers; initially mandatory, subsequent disclosures edge towards voluntariness unless specifically required for eligibility verification purposes. Furthermore, CalPERS ensures that any transfer of this information to other state agencies, physicians, and insurance carriers happens within the rigid boundaries set by confidentiality laws, safeguarding member's information while maintaining accessibility rights to one's membership files, underscored by a transparent communication channel for any inquiries or concerns.

QuestionAnswer
Form NameHbd 12 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesbenefit plan enrollment, ca form health enrollment, calpers hbd 12 form, form health enrollment

Form Preview Example

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Khdowk#Dffrxqw#Pdqdjhphqw#Glylvlrq

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S1R1#BR[#<75:18#

 

 

 

 

 

 

 

 

Khdowk#Ehqhilwv#Sodq#Hquroophqw#

Vdfudphqwr/#FD#<755<-5:18

 

 

 

 

 

 

;;;#FdoSHUV#(ru#;;;-558-:6::)#⦅#WW\#(8::)#57<-:775

 

 

 

iru#Dfwlyh#Hpsor|hhv#+KEG045,#

ID[#(800)#<8<-9878

 

 

 

 

 

 

 

 

zzz1fdoshuv1fd1jrv

 

 

 

 

 

VHFWLRQ#D=#Dssolfdqw#Lqirupdwlrq

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

41#

#Hpsor|hh#Qdph=#

(First)

 

 

 

 

(M.I.)

 

 

 

 

 

(Last)

 

 

 

51#

Kluh#Gdwh=#(pp/gg/||||)#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

61#

FdoSHUV#LG#ru#Vrfldo#Vhfxulw|#Qxpehu=#

71

 

Gdwh#ri#Eluwk=(mm/dd/yyyy)

 

 

 

81#

Jhqghu=#

 

Pdoh#

Ihpdoh#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

91#

#Uhvlghqfh#Dgguhvv=#(Street)

 

 

 

 

 

 

 

 

 

 

(City)

 

 

(State)

 

(ZIP)

 

 

(County)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:1#

#Pdlolqj#Dgguhvv(Li#gliihuhqw)=# (Street)

 

 

 

 

 

 

 

 

 

(City)

 

 

(State)

 

(ZIP)

 

 

(County)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

;1

Xvh#Zrun#]LS#Frgh#iru#Khdowk#Holjlelolw|=

 

 

\hv

Qr If yes, enter zip code here: (ZIP)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

<1#

H0pdlo#Dgguhvv=

 

 

 

 

 

 

 

 

 

431#

Sulpdu|#Skrqh=#

 

 

 

 

Dowhuqdwh=#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VHFWLRQ#E=#W|sh#ri#Dfwlrq#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

441#

Hquroo#lq#d#Hhdowk#Sodq#

Dgg/Dhohwh#Dhshqghqwv

 

 

Fkdqjh#Hhdowk#Sodq

Fdqfho#Doo#Frvhudjh

 

Dhfolqh#Frvhudjh

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VHFWLRQ#F=#W|sh#ri#Shuplwwlqj#Hyhqw#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

451#

Qhz#Hpsor|hh#

Qhz#Frqwudfwlqj

 

Pduuldjh#ru#Drphvwlf#Sduwqhuvkls#Ddwh#(mm/dd/yyyy)=#

 

 

 

Rshq

 

Prvh#

 

 

Djhqf|#

 

 

 

 

 

 

 

 

 

 

 

 

 

Bluwk/

 

 

 

Hquroophqw#

 

 

 

Dhohwh#Dhshqghqw#Dxh#wr#Dhdwk#

Dlvrufh#ru#Drphvwlf#Sduwqhuvkls#Whuplqdwlrq#

Rwkhu=#

 

 

 

 

 

 

Dgrswlrq#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

461#

Shuplwwlqj#Hyhqw#Gdwh=#(pp/gg/||||)#

471#

#Qdph#ri#Khdowk#Sodq=#(Li#fkdqjlqj#khdowk#sodqv/#olvw#qhz#sodq#qdph)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VHFWLRQ#G=#Vxevfulehu#dqg#Ghshqghqw#Lqirupdwlrq#

(Olvw#|rxuvhoi#dqg#doo#ri#|rxu#ghshqghqwv#wr#eh#hquroohg#rq#|rxu#khdowk#sodq)

481

Qdph#+Iluvw/#P1L1/#Odvw,#

 

Uhodwlrqvkls

 

Jhqghu

 

Gdwh#ri#

 

FdoSHUV#LG#ru#Vrfldo#

Dfwlrq

 

Sulpdu|#Fduh#

 

 

 

Frgh#-1

 

 

Eluwk#

 

Vhfxulw|#Qxpehu#

 

Sk|vlfldq

 

 

 

 

 

 

 

 

 

 

 

 

 

(pp/gg/||||)#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VHOI#

 

 

Pdoh

 

 

 

 

 

 

 

Dgg#

 

 

 

 

 

 

 

 

 

 

 

 

Ihpdoh#

 

 

 

 

 

 

 

Dhohwh#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pdoh#

 

 

 

 

 

 

 

Dgg#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ihpdoh#

 

 

 

 

 

 

 

Dhohwh#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pdoh#

 

 

 

 

 

 

 

Dgg#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#Ihpdoh#

 

 

 

 

 

 

 

Dhohwh#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#Pdoh

 

 

 

 

 

 

 

Dgg#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ihpdoh

 

 

 

 

 

 

 

Dhohwh#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#Pdoh#

 

 

 

 

 

 

 

Dgg#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#Ihpdoh

 

 

 

 

 

 

 

Dhohwh#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#Pdoh

 

 

 

 

 

 

 

Dgg#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#Ihpdoh#

 

 

 

 

 

 

 

Dhohwh#

 

 

 

 

 

1#Uhodwlrqvkls#Frghv= V#-Vsrxvh#

GS#-#Drphvwlf#Sduwqhu#

QF#-#Qdwxudo#Fklog#

VF#-#Vwhs#Fklog#

DF#-#Dgrswhg#Fklog#

GSF#-#Drphvwlf#Sduwqhu#Fklog#

SFU#-#Sduhqw#Fklog#Rhodwlrqvkls

VHFWLRQ#H=#Hquroophqw#

491 Wr#hquroo/#fduhixoo|#uhylhz#wkh#lqirupdwlrq#lq#wklv#vhfwlrq#dqg#fkhfn#wkh#er{=

L#HOHFW#WR#HQUROO#lq#(ru#PDNH#FKDQJHV#WR)#d#khdowk#ehqhilwv#sodq#dv#lqglfdwhg#dervh#dqg#djuhh#wr#dxwkrul}h#ghgxfwlrqv#iurp#p|#vdodu|#wr#frvhu#p| vkduh#ri#wkh#frvw#ri#hquroophqw#dv#lw#lv#qrz#ru#dv#lw#pd|#eh#lq#wkh#ixwxuh1# L#FHUWLI\#wkdw#wkh#lqirupdwlrq#survlghg#khuhlq#lv#dffxudwh#dqg#olvwhg#ghshqghqwv duh#holjleoh#idplo|#phpehuv#dv#ghilqhg#lq#wkh#Sxeolf#Hpsor|hhv*#Phglfdo#dqg#Hrvslwdo#Fduh#Dfw1

##

L#YROXQWDULO\#hquroo#lqwr#wkh#vhohfwhg#Hhdowk#Sodq1#L#DJUHH#wr#uhdg#wkh#dvvrfldwhg#Hvlghqfh#ri#Frvhudjh#(HRF)#dqg#dq|#vxevhtxhqw#HRFv#lq#wkh

iroorzlqj#|hduv#wr#xqghuvwdqg#wkh#ehqhilwv#ri#wkh#sodq1#Wkh#Vxevfulehu#dqg#doo#holjleoh#ghshqghqwv#djuhh#wr#doo#wkh#whupv#dqg#frqglwlrqv#ri#wkh#HRF#dqg#wkh Hhdowk#Sodq1

##

L#XQGHUVWDQG#wkdw#hquroolqj#lq#fhuwdlq#khdowk#sodqv#uhtxluhv#elqglqj#duelwudwlrq#dqg#wkdw#dq|#glvsxwh#dv#wr#phglfdo#pdosudfwlfh/#wkdw#lv#dv#wr#zkhwkhu#dq| phglfdo#vhuvlfhv#uhqghuhg#xqghu#wklv#frqwudfw#zhuh#xqqhfhvvdu|#ru#xqdxwkrul}hg#ru#zhuh#lpsurshuo|/#qhjoljhqwo|/#ru#lqfrpshwhqwo|#uhqghuhg/#zloo#eh

ghwhuplqhg#e|#vxeplvvlrq#wr#duelwudwlrq#dv#survlghg#e|#Fdoliruqld#Odz#dqg#qrw#e|#d#odzvxlw#ru#uhvruw#wr#frxuw#surfhvv#h{fhsw#dv#Fdoliruqld#odz#survlghv#iru mxglfldo#uhvlhz#ri#duelwudwlrq#surfhhglqjv1#Wkh#sduwlhv#wr#wklv#djuhhphqw/#e|#hqwhulqj#lqwr#lw/#duh#jlvlqj#xs#wkhlu#frqvwlwxwlrqdo#uljkw#wr#kdvh#dq|#vxfk#glvsxwh ghflghg#lq#d#frxuw#ri#odz#ehiruh#d#mxu|#dqg#lqvwhdg#duh#dffhswlqj#wkh#xvh#ri#duelwudwlrq1

4:1# Wr#ghfolqh/#fduhixoo|#uhylhz#wkh#lqirupdwlrq#lq#wklv#vhfwlrq#dqg#fkhfn#wkh#er{=#

L#GHFOLQH#HQUROOPHQW#lqwr#wkh#FdoSHRV#Hhdowk#Surjudp#iru#p|vhoi#dqg#p|#ghshqghqwv1#

##

L#XQGHUVWDQG#wkdw#li#L#fkrrvh#wr#hquroo#dw#d#odwhu#gdwh/#L#pxvw#zdlw#dw#ohdvw#<0#gd|v#diwhu#L#uhtxhvw#hquroophqw#ru#xqwlo#wkh#qh{w#Rshq#Hquroophqw#(RH)#shulrg ehiruh#hquroolqj#lq#wkh#FdoSHRV#Hhdowk#Surjudp1#Ixuwkhupruh/#li#L#ru#p|#ghshqghqwv#lqvroxqwdulo|#orvh#rwkhu#khdowk#lqvxudqfh#frvhudjh/#L#pd|#uhtxhvw

hquroophqw#lqwr#wkh#Surjudp#zlwklq#90#gd|v#iurp#wkh#gdwh#ri#orvw#frvhudjh1#Li#L#gr#qrw#uhtxhvw#hquroophqw#zlwklq#90#gd|v/#L#pxvw#zdlw#dw#ohdvw#<0#gd|v#ru#xqwlo wkh#qh{w#RH#shulrg#ehiruh#L#fdq#hquroo1#Wkh#hiihfwlvh#gdwh#ri#frvhudjh#zloo#eh#wkh#iluvw#ri#wkh#prqwk#iroorzlqj#wkh#<0#gd|#zdlwlqj#shulrg#ru#wkh#RH#hiihfwlvh gdwh1#

4;1#

Hpsor|hh#Vljqdwxuh=#

4<1#

#Gdwh=(mm/dd/yyyy)

 

 

 

HBD-15#(Rhv#01/5018)#

Sdjh#1#ri#5#

VHFWLRQ#I=#FdoSHUV#Sulydf|#Qrwlfh#

Wkh#sulvdf|#ri#shuvrqdo#lqirupdwlrq#lv#ri#wkh#

VVQ#

xwprvw#lpsruwdqfh#wr#FdoSHRV1#Wkh#iroorzlqj#

Vrfldo#Vhfxulw|#qxpehuv#duh#froohfwhg#rq#d#

lqirupdwlrq#lv#survlghg#wr#|rx#lq#frpsoldqfh#zlwk#

pdqgdwru|#dqg#vroxqwdu|#edvlv1#Li#wklv#lv#FdoSHRV#

wkh#Lqirupdwlrq#Sudfwlfhv#Dfw#ri#1<::#dqg#wkh#

iluvw#uhtxhvw#iru#glvforvxuh#ri#|rxu#VVQ/#wkhq#

Ihghudo#Sulvdf|#Dfw#ri#1<:71#

glvforvxuh#lv#pdqgdwru|1#Li#|rxu#VVQ#kdv#douhdg|#

##

ehhq#survlghg/#glvforvxuh#lv#vroxqwdu|1#Dxh#wr#wkh#

Lqirupdwlrq#Sxusrvh#

xvh#ri#Vrfldo#Vhfxulw|#qxpehuv#e|#rwkhu#djhqflhv#

Wkh#lqirupdwlrq#uhtxhvwhg#lv#froohfwhg#sxuvxdqw#

iru#lghqwlilfdwlrq#sxusrvhv/#zh#pd|#eh#xqdeoh#wr#

wr#wkh#Jrvhuqphqw#Frgh#Vhfwlrqv#(50000########

vhuli|#holjlelolw|#iru#ehqhilwv#zlwkrxw#wkh#qxpehu1#

hw#vht1)#dqg#zloo#eh#xvhg#iru#dgplqlvwudwlrq#ri#

##

Brdug#gxwlhv#xqghu#wkh#Rhwluhphqw#Odz/#wkh#

Vrfldo#Vhfxulw|#qxpehuv#duh#xvhg#iru#wkh#iroorzlqj#

Vrfldo#Vhfxulw|#Dfw/#dqg#wkh#Sxeolf#Hpsor|hhv*#

sxusrvhv=#

Phglfdo#dqg#Hrvslwdo#Fduh#Dfw/#dv#wkh#fdvh#pd|#

11 Hquroohh#lghqwlilfdwlrq

eh1#Vxeplvvlrq#ri#wkh#uhtxhvwhg#lqirupdwlrq#lv#

51 Sd|uroo#ghgxfwlrq#/#vwdwh#frqwulexwlrqv

pdqgdwru|1#Idloxuh#wr#frpso|#pd|#uhvxow#lq#wkh#

61 Bloolqj#ri#frqwudfwlqj#djhqflhv#iru#hpsor|hh#/

v|vwhp#ehlqj#xqdeoh#wr#shuirup#lwv#ixqfwlrqv#

hpsor|hu#frqwulexwlrqv

uhjduglqj#|rxu#vwdwxv1#

71 Rhsruwv#wr#wkh#FdoSHRV#v|vwhp#dqg#rwkhu

##

vwdwh#djhqflhv

Sohdvh#gr#qrw#lqfoxgh#lqirupdwlrq#wkdw#lv#qrw#

81 Frruglqdwlrq#ri#ehqhilwv#dprqj#fduulhuv

uhtxhvwhg1#

 

VHFWLRQ#J=#Sulydf|#Lqirupdwlrq#

 

91 Rhvrovh#phpehu#dsshdov/#frpsodlqwv/#ru julhvdqfhv#zlwk#khdowk#sodq#fduulhuv

##

Lqirupdwlrq#Glvforvxuh#

Sruwlrqv#ri#wklv#lqirupdwlrq#pd|#eh#wudqvihuuhg#wr# rwkhu#vwdwh#djhqflhv#(vxfk#dv#|rxu#hpsor|hu)/#

sk|vlfldqv/#dqg#lqvxudqfh#fduulhuv/#exw#rqo|#lq#

vwulfw#dffrugdqfh#zlwk#fxuuhqw#vwdwxwhv#uhjduglqj# frqilghqwldolw|1#

##

\rxu#Uljkwv#

\rx#kdvh#wkh#uljkw#wr#uhvlhz#|rxu#phpehuvkls# ilohv#pdlqwdlqhg#e|#wkh#v|vwhp1#Iru#txhvwlrqv# derxw#wklv#qrwlfh/#rxu#Sulvdf|#Srolf|/#ru#|rxu#

uljkwv/#sohdvh#zulwh#wkh#FdoSHRV#Sulvdf|#Riilfhu# dw#700#T#Vwuhhw/#Vdfudphqwr/#FD#<8811#ru#fdoo# rxu#Fxvwrphu#Frqwdfw#Fhqwhu#dw#888-FdoSHRV# (888-558-:6::)1#

Vxeplvvlrq#ri#wkh#uhtxhvwhg#lqirupdwlrq#lv#pdqgdwru|1#Wkh#lqirupdwlrq#uhtxhvwhg#lv#froohfwhg#sxuvxdqw#wr#wkh#Fdoliruqld#Jrvhuqphqw#Frgh#(vhfwlrqv# 50000#hw#vht1)#dqg#lv#xvhg#iru#dgplqlvwudwlrq#ri#wkh#FdoSHRV#Brdug*v#gxwlhv#xqghu#wkh#Sxeolf#Hpsor|hhv*#Rhwluhphqw#Odz/#wkh#Vrfldo#Vhfxulw|#Dfw/#dqg# wkh#Sxeolf#Hpsor|hhv*#Phglfdo#dqg#Hrvslwdo#Fduh#Dfw/#dv#wkh#fdvh#pd|#eh1#Sruwlrqv#ri#wklv#lqirupdwlrq#pd|#eh#wudqvihuuhg#wr#rwkhu#jrvhuqphqwdo#

djhqflhv#(vxfk#dv#|rxu#hpsor|hu)/#sk|vlfldqv#dqg#lqvxudqfh#fduulhuv#exw#rqo|#lq#vwulfw#frpsoldqfh#zlwk#fxuuhqw#vwdwxwhv#uhjduglqj#frqilghqwldolw|1#Idloxuh# wr#vxsso|#wkh#lqirupdwlrq#pd|#uhvxow#lq#FdoSHRV#ehlqj#xqdeoh#wr#shuirup#lwv#ixqfwlrqv#uhjduglqj#|rxu#vwdwxv1#

##

\rx#kdvh#wkh#uljkw#wr#uhvlhz#|rxu#FdoSHRV#phpehuvkls#ilohv1#Iru#txhvwlrqv#frqfhuqlqj#|rxu#uljkwv#xqghu#wkh#Lqirupdwlrq#Sudfwlfhv#Dfw#ri#1<::/#sohdvh# frqwdfw#wkh#FdoSHRV#Fxvwrphu#Frqwdfw#Fhqwhu#dw#40;;;0FdoSHUV#(ru#1-888-558-:6::)1#

###

Vhfwlrq#:(e)#ri#wkh#Sulvdf|#Dfw#ri#1<:7#(Sxeolf#Odz#<6-8:<)#uhtxluhv#wkdw#dq|#ihghudo/#Vwdwh/#ru#orfdo#jrvhuqphqwdo#djhqf|##uhtxhvwlqj#dq#lqglvlgxdo#wr# glvforvh#d#Vrfldo#Vhfxulw|#dffrxqw#qxpehu#wr#lqirup#wkh#lqglvlgxdo#zkhwkhu#wkdw#glvforvxuh#lv#pdqgdwru|#ru#vroxqwdu|/#e|#zklfk#vwdwxwru|#ru#rwkhu#

dxwkrulw|#vxfk#qxpehu#lv#vrolflwhg/#dqg#zkdw#xvhv#zloo#eh#pdgh#ri#lw1#Vhfwlrq#111#ri#Sxeolf#Odz#101-1:6#uhtxluhv#jurxs#khdowk#sodqv#wr#froohfw#dqg#

survlgh#phpehu#Vrfldo#Vhfxulw|#qxpehuv#iru#wkh#frruglqdwlrq#ri#ihghudo#dqg#Vwdwh#ehqhilwv1#Ixuwkhupruh/#wkh#FdoSHRV#khdowk#surjudp#uhtxluhv#hdfk# hquroohh*v#Vrfldo#Vhfxulw|#qxpehu#iru#lghqwlilfdwlrq#sxusrvhv#dqg#wr#vhuli|#holjlelolw|#iru#ehqhilwv1##

##

Wkh#FdoSHRV#khdowk#surjudp#xvhv#Vrfldo#Vhfxulw|#qxpehuv#iru#wkh#iroorzlqj#sxusrvhv=#

##

11

Hquroohh#lghqwlilfdwlrq#iru#holjlelolw|#surfhvvlqj#dqg#holjlelolw|#vhulilfdwlrq

 

 

51

Sd|uroo#ghgxfwlrq#dqg#Vwdwh#frqwulexwlrq#iru#Vwdwh#hpsor|hhv1

 

61

Bloolqj#ri#frqwudfwlqj#djhqflhv#iru#hpsor|hh#dqg#hpsor|hu#frqwulexwlrqv1

 

71

Rhsruwv#wr#FdoSHRV#dqg#rwkhu#vwdwh#djhqflhv1

 

81

Frruglqdwlrq#ri#ehqhilwv#dprqj#khdowk#sodqv1

91 Rhvroxwlrq#ri#phpehu#frpsodlqwv/#julhvdqfhv#dqg#dsshdov#zlwk#khdowk#sodqv1

##

LPSRUWDQW=# Lw#lv#|rxu#uhvsrqvlelolw|#wr#qrwli|#|rxu#shuvrqqho#riilfh#zkhq#wkhuh#duh#dq|#fkdqjhv#lq#|rxu#idplo|#vlwxdwlrq1#Fkdqjhv#lqfoxgh#grphvwlf# sduwqhuvkls#whuplqdwlrq/#hvwdeolvkphqw#ri#d#sduhqw-fklog#uhodwlrqvkls/#dftxlvlwlrq#ri#d#ghshqghqw#fklog/#fkdqjh#ri#dgguhvv/#pduuldjh/#glvrufh/#ohjdo#

vhsdudwlrq/#dqg#ghdwk1#Idloxuh#wr#qrwli|#|rxu#shuvrqqho#riilfh#pd|#uhvxow#lq#dgvhuvh#frqvhtxhqfhv1#

VHFWLRQ#K=#Iru#Hpsor|hu#Xvh#

 

Sohdvh#uhwdlq#ruljlqdo#vljqhg#irup#dqg#doo#vxssruwlqj#grfxphqwdwlrq#ru#diilgdylwv#lq#hpsor|hh#iloh1#GR#QRW#vhqg#wr#FdoSHUV1#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

531#

Djhqf|#Qdph=#

 

541

Gdwh#ri#Kluh=#(mm/dd/yyyy)

 

551#

Uhwluhphqw#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V|vwhp=#

FdoSHRV#

FdoVWRV

Rwkhu

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

561#

#FdoSHUV#Hpsor|hu#LG=

 

571

#Glylvlrq#LG=

 

 

581

#Hpsor|hh#Edujdlqlqj#Xqlw2Hpsor|hh#Jurxs=

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

591

Sd|uroo

Vwdwh#Frqwuroohu*v#

 

 

Sxeolf#Djhqf|#

 

5:1

#Gdwh#Uhfhlyhg#e|#Hpsor|hu=

 

5;

 

(mm/dd/yyyy)

 

Riilfh=

Qrq#Fhqwudo#

 

 

 

 

#Hiihfwlyh#Gdwh=

 

 

Riilfh#

Bloolqj#

 

 

 

 

 

 

 

 

 

 

 

L#khuhe|#fhuwli|#xqghu#wkh#shqdow|#ri#shumxu|#wkdw#L#dp#d#gxo|#dssrlqwhg/#txdolilhg#dqg#dfwlqj#Hhdowk#Bhqhilwv#Riilfhu#(HBR)#ri#wkh#dervh#qdphg#djhqf|/#dqg#wkh# sd|phqw#e|#wkh#djhqf|#dv#survlghg#e|#Vhfwlrq#558:0-55<08#ri#wkh#Jrvhuqphqw#Frgh#lv#khuhe|#dssurvhg1#Ilqdo#ghwhuplqdwlrq#ri#holjlelolw|#iru#wkh#hquroophqw# dfwlrq#vshflilhg#zloo#eh#pdgh#e|#wkh#Brdug#ri#Dgplqlvwudwlrq/#Sxeolf#Hpsor|hhv*#Rhwluhphqw#V|vwhp/#lq#dffrugdqfh#zlwk#wkh#Sxeolf#Hpsor|hhv*#Phglfdo#dqg# Hrvslwdo#Fduh#Dfw#dqg#wkh#uhjxodwlrqv#lpsohphqwlqj#wkh#Dfw1#

5<1#

(Sulqw#qdph)

631

#Vljqdwxuh=#

641

(mm/dd/yyyy)

651#

#Skrqh#Qxpehu=

 

#Khdowk#Ehqhilwv#Riilfhu=#

 

 

#Gdwh=

 

 

 

 

 

 

 

 

 

661# #Uhpdunv=

HBD-15#(Rhv#01/5018)#

Sdjh#5#ri#5#

Privacy Notice

The privacy of personal information is of the utmost importance to CalPERS. The following information is provided to you in compliance with the Information Practices Act of 1977 and the Federal Privacy Act of 1974.

Information Purpose

The information requested is collected pursuant to the Government Code (sections 20000 et seq.) and will be used for administration of Board duties under the Retirement Law, the Social Security Act, and the Public Employees’ Medical and Hospital Care Act, as the case may be. Submission of the requested information is mandatory. Failure to comply may result in CalPERS being unable to perform its functions regarding your status.

Please do not include information that is not requested.

Social Security Numbers

Social Security numbers are collected on a mandatory and voluntary basis. If this is CalPERS’ irst request for disclosure of your Social Security number, then disclosure is mandatory. If your Social Security number has already been provided, disclosure is voluntary. Due to the use of Social Security numbers by other agencies for identiication purposes, we may be unable to verify eligibility for beneits without the number.

Social Security numbers are used for the following purposes:

1.Enrollee identiication

2.Payroll deduction/state contributions

3.Billing of contracting agencies for employee/ employer contributions

4.Reports to CalPERS and other state agencies

5.Coordination of beneits among carriers

6.Resolving member appeals, complaints, or grievances with health plan carriers

Information Disclosure

Portions of this information may be transferred to other state agencies (such as your employer), physicians, and insurance carriers, but only

in strict accordance with current statutes regarding conidentiality.

Your Rights

You have the right to review your membership iles maintained by the System. For questions about this notice, our Privacy Policy, or your rights, please write to the CalPERS Privacy Oicer at

400 Q Street, Sacramento, CA 95811 or call us at 888 CalPERS (or 888-225-7377).

May 2016

How to Edit Hbd 12 Form Online for Free

Any time you intend to fill out calpers form enrollment, you won't need to download and install any kind of software - just try our PDF editor. Our tool is continually developing to grant the very best user experience achievable, and that's due to our resolve for continuous enhancement and listening closely to comments from customers. Starting is simple! All you have to do is take these simple steps below:

Step 1: Simply press the "Get Form Button" at the top of this site to start up our pdf editor. Here you will find everything that is required to work with your file.

Step 2: With this handy PDF tool, it is easy to do more than merely complete forms. Express yourself and make your documents appear sublime with custom textual content incorporated, or tweak the file's original input to perfection - all comes along with an ability to add any type of pictures and sign it off.

As a way to complete this form, be certain to provide the right details in every field:

1. The calpers form enrollment requires certain details to be typed in. Ensure the subsequent fields are finalized:

Part number 1 of filling out hbd 12 form calpers

Step 3: When you've glanced through the information in the file's blanks, press "Done" to finalize your form at FormsPal. Right after starting a7-day free trial account with us, you will be able to download calpers form enrollment or send it through email promptly. The PDF file will also be readily accessible from your personal cabinet with your every single edit. We don't share any details that you type in whenever filling out forms at our website.