Form Std 692 PDF Details

Navigating through the complexities of health benefits in employment can be a daunting task, but understanding the tools and forms that facilitate these benefits can make the process smoother. The State of California Dental Plan Enrollment Authorization, known by its form number, STD. 692 (revised June 2000), serves as a critical document for employees within the state to manage their dental plan enrollment. Designed to be filled out with either a ballpoint pen or typed, the STD. 692 form requires attention to detail and clear printing to ensure accurate processing. The form accommodates multiple scenarios, including enrolling in a plan for the first time, making changes to existing plans or coverage for dependents, and even canceling coverage altogether. Sections within the form gather essential information, such as the type of action being requested, personal details of the employee, and specifics about the dental plan being enrolled in or changed. Whether employees are navigating new coverage options, updating their dependents’ status, or cancelling their plan, this form stands as the gateway to executing their dental health benefits. Additionally, it includes a section for privacy notice, informing employees about the handling of their personal information and their rights concerning it, underlining the importance of transparency and confidentiality in the process of enrolling in dental coverage.

QuestionAnswer
Form NameForm Std 692
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshuman_resources _dental_plan_en rollment_author ization_std692 csudh dental insurance form

Form Preview Example

STATE OF CALIFORNIA

DENTAL PLAN ENROLLMENT AUTHORIZATION

STD. 692 (REV. 6-2000)

PLEASE TYPE OR USE BALL POINT PEN, PRINT CLEARLY--SEND COMPLETED FORM TO PERSONNEL/PAYROLL OFFICE

SECTION A

 

 

 

 

 

 

 

 

SECTION B

 

 

 

1. TYPE OF ACTION

 

 

 

 

 

 

 

 

1. NAME OF DENTAL PLAN

 

 

 

 

 

NEW - ENROLLING IN A PLAN FOR THE FIRST TIME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Complete Sections A, B, and D)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CANCEL - CANCELLING COVERAGE FOR ALL ENROLLEES

 

 

 

 

2. PROVIDER/FACILITY NUMBER (If applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Complete Sections A, C, and D)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHANGE - CHANGING PLANS OR DEPENDENT COVERAGE

 

 

 

 

3. WHEN CHANGING FAMILY MEMBER ENROLLMENT, LIST ALL FAMILY MEMBERS CURRENTLY ENROLLED, AS

 

 

 

 

 

 

 

WELL AS FAMILY MEMBERS TO BE ADDED AND/OR DELETED. ENTER THE ACTION CODE A (ADD) AND/OR D

 

 

(Complete Sections A, B, C, and D)

 

 

 

 

 

(DELETE) BESIDE THE NAMES OF ONLY THOSE MEMBERS TO BE ADDED OR DELETED.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. SOCIAL SECURITY NUMBER

 

3. SPOUSE’S OR DOMESTIC PARTNER’S SOCIAL SECURITY

A

 

LIST ALL PERSONS TO BE ENROLLED IN

 

 

 

C C

 

DATE OF BIRTH

 

 

 

 

 

NUMBER

 

 

 

 

T O

 

DENTAL PLAN (include self)

 

 

 

 

 

 

 

 

 

I D

 

 

FAMILY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O E

(First)

(Middle)

(Last)

MONTH DAY YEAR RELATIONSHIP

 

 

 

 

 

 

 

 

 

 

 

 

 

N

 

4. NAME

(First)

(Middle)

(Last)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SELF

 

ADDRESS

(Number and Street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(City, State, and Zip)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. CHECK IF PERMANENT

 

6. MARITAL STATUS

 

7. SEX

 

 

 

 

 

 

 

INTERMITTENT EMPLOYEE

 

 

MARRIED

 

 

SINGLE

 

 

MALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOMESTIC PARTNER

 

 

FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION C (Complete for Plan changes if different than B-1 and cancellations only)

1. PRIOR DENTAL PLAN NAME

SECTION D

1. CHECK APPROPRIATE BOX

I DO NOT WISH TO ENROLL IN A DENTAL PLAN (Keep in employee’s file)

I ELECT TO ENROLL IN (OR CHANGE TO) A DENTAL PLAN AS SHOWN ABOVE AND AUTHORIZE DEDUCTIONS TO BE MADE FROM MY SALARY OR RETIREMENT ALLOWANCE TO COVER MY SHARE OF COST OF ENROLLMENT AS IT IS NOW OR AS IT MAY BE IN THE FUTURE. I ALSO CERTIFY THAT THE NAMES OF THE PERSONS LISTED IN SECTION B, ITEM 3 ARE ELIGIBLE FAMILY MEMBERS AS DEFINED BY THE STATE OF CALIFORNIA AND ARE NOT ENROLLED IN ANOTHER STATE OF CALIFORNIA DENTAL PLAN.

I ELECT TO CANCEL THE DENTAL PLAN SHOWN ABOVE

2.EMPLOYEE’S OR ANNUITANT’S SIGNATURE (See Privacy Information on reverse of employee copy.)

�

3. DATE SIGNED

SECTION E (FOR AGENCY OR RETIREMENT SYSTEM USE ONLY)

1. EMPLOYER DED. CODE

2. DENTAL ORG. CODE

3. EMPLOYEE or COBEN

 

4.

PARTY CODE

5. STATE

 

6. PAY PERIOD

7.

EMPLOYEE

8.

BARGAINING

 

9. TOTAL PREMIUM

 

 

 

 

 

DEDUCTION AMOUNT

 

 

 

SHARE

 

 

 

 

 

DESIGNATION

 

UNIT

 

AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

CSU-150

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NON-CSU-351

 

 

 

 

 

 

 

 

 

 

 

 

 

MONTH

 

YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

$

 

 

.

 

 

 

 

 

 

 

 

$

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETE ON CHANGES ONLY

 

12. PERMITTING

 

13.

PERMITTING

14.

EFFECTIVE DATE

15. AGENCY CODE

16.

UNIT CODE

17.

AGENCY NAME OR RETIREMENT SYSTEM

 

 

 

EVENT

 

 

 

 

EVENT

 

OF ACTION

 

 

 

 

 

 

 

(IF RETIRED)

 

10. PRIOR EMPLOYER DED. CODE

11. PRIOR

PRIOR

DATE

 

 

 

 

CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DENTAL

PARTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ORG.

CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CSU-150

CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NON-CSU-351

 

 

MONTH

 

DAY

 

YEAR

 

 

MONTH

 

DAY

YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

- 1 -

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. REMARKS

 

 

 

 

 

 

 

 

 

19. AUTHORIZED AGENCY SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby certify under penalty of perjury as follows: That I am the duly appointed, qualified and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

acting officer of the herein named agency and that I am authorized to make this certification; that

 

 

 

 

 

 

 

 

 

 

 

 

 

the employee named herein is eligible for enrollment in the State Dental Insurance Program.

 

 

 

 

 

 

 

 

 

 

 

 

 

�

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. TELEPHONE NUMBER (Indicate if CALNET or give Area Code)

21. DATE RECEIVED IN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYING OFFICE

MONTH

DAY

YEAR

WHITE - To Controller

YELLOW - To Carrier

PINK - To Agency

GREEN - To Employee

STATE OF CALIFORNIA

DENTAL PLAN ENROLLMENT AUTHORIZATION

STD. 692 (REV. 6-2000) (REVERSE)

PRIVACY NOTICE

The Information Practices Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act (Public Law 93-579) require that this notice be provided when collecting personal information from individuals.

Information requested on this form is used by the State Controller’s Office and the dental insurance company for the purposes of identification and dental coverage processing.

It is mandatory to furnish all information requested on this form except for employee’s gender and marital status, which may be furnished on a voluntary basis and are used by the dental insurance company for statistical and actuarial purposes. Failure to provide the mandatory information may result in the dental enrollment action not being processed or being processed incorrectly.

The State Controller’s Office requires employee’s social security number and name for identification purposes. Legal references authorizing maintenance of this information include Government Code Sections 1151, 1153, Sections 6011 and 6051 of the Internal Revenue Code, and Regulation 4, Section 404.1256, Code of Federal Regulations, under Section 218, Title II of the Social Security Act.

Information provided on the form will be forwarded to the dental insurance company providing coverage for the employee. Copies of the Dental Plan Enrollment Authorization are maintained in confidential files of the State Controller’s Office for five years. Employees have the right of access to copies of their Dental Plan Enrollment Authorization forms upon request. Send requests to: State Controller’s Office, Personnel/Payroll Operations Bureau, P. O. Box 942850, Sacramento, California 94250-5878, Attention: Benefits Unit.

How to Edit Form Std 692 Online for Free

Handling PDF documents online is certainly very simple with this PDF editor. Anyone can fill in Form Std 692 here effortlessly. Our editor is constantly developing to give the very best user experience attainable, and that is thanks to our resolve for constant improvement and listening closely to feedback from customers. This is what you will want to do to start:

Step 1: Press the "Get Form" button in the top section of this page to access our editor.

Step 2: With this state-of-the-art PDF editor, you'll be able to do more than just fill in blank fields. Express yourself and make your docs appear perfect with customized textual content added in, or modify the file's original content to perfection - all comes with the capability to incorporate any type of images and sign it off.

Be mindful while completing this document. Ensure each and every blank is filled out accurately.

1. When filling in the Form Std 692, make certain to complete all important fields in its relevant section. It will help to speed up the process, which allows your information to be handled promptly and properly.

Step no. 1 of submitting Form Std 692

2. Right after the last array of blanks is filled out, go to enter the suitable information in these - PRIOR DENTAL PLAN NAME, SECTION D, CHECK APPROPRIATE BOX, I DO NOT WISH TO ENROLL IN A, SSN, SSN, SSN, Dependent Type S Spouse DP, C Child SC Stepchild, DPC Domestic Partner Child PCR, I ELECT TO ENROLL IN OR CHANGE TO, I ELECT TO CANCEL THE DENTAL PLAN, EMPLOYEES OR ANNUITANTS SIGNATURE, DATE SIGNED, and SECTION E FOR AGENCY OR RETIREMENT.

Form Std 692 completion process outlined (part 2)

3. The next step is easy - fill in every one of the fields in I hereby certify under penalty of, TELEPHONE NUMBER Include Area Code, EMAIL ADDRESS, DATE RECEIVED IN EMPLOYING OFFICE, Month Day, Year, and Distribute one copy each to in order to finish the current step.

Part no. 3 of filling out Form Std 692

You can certainly make a mistake when filling out the Year, thus make sure to reread it prior to deciding to send it in.

Step 3: Prior to addressing the next step, it's a good idea to ensure that all blanks have been filled in the correct way. When you verify that it is good, press “Done." Obtain the Form Std 692 once you sign up for a free trial. Readily get access to the pdf form within your FormsPal account, with any modifications and adjustments all preserved! Here at FormsPal, we do our utmost to be certain that your details are stored private.

Form Std 692 isn’t the one you’re looking for?

Related Documents