ACTIVE Enrollment / Change Forms

Choose the applicable Enrollment / Change Form for the Health Plan selection you are choosing.

Important:

For Kaiser Permanente and Blue Shield of California HMO Plans, there are limited coverage service areas within Northern California.

Blue Shield of California Plans are not available to all Classifications. Refer to your Summary Plan Description for details.

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Blue Shield of California PPO and HMO Active Enrollment / Change Form
Kaiser Permanente HMO Active Enrollment / Change Form

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