Hbd 12 Form PDF Details

Are you familiar with the hbd 12 form? It is an incredibly important document that often gets overlooked or misunderstood. If you are unaware of what it entails, this post will provide a comprehensive overview of what it is and how it can be used to your advantage. From its history and origins, to providing information on where to find official documents related to the hbd 12 form- this blog post is here to clear up any confusion and equip you with all the knowledge necessary for successful completion of this essential piece of paperwork.

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

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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

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