RETIREE 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.

The Blue Shield of California HMO Plan is not available if a Participant and/or any Dependents are eligible for Medicare.

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

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