Form Dr25a - Federal Employees Health Benefits Program - 2015

Page 2

FEDERAL EMPLOYEES

HEALTH BENEFITS

FEHB

Read the enclosed instructions before completing this form. Return this form to:

PROGRAM

USDA/NFC, DPRS Billing Unit, P.O. Box 61760, New Orleans, LA 70161

You may fax your form to 303-274-3805.

OPEN SEASON

Do not take any action to maintain your present coverage.

DPRS-2809

OMB 0505-0024

COMPLETE THIS FORM

IF YOU ARE MAKING CHANGES.

ONLY

(Revised 10/15)

All plan brochure requests must be made through the carrier from whom you wish to receive the brochure

or from the FEHB web site at

SECTION I - Enrollee and Family Member Information

(For additional family members use a separate sheet and attach.)

(last, first, middle initial)

(mm/dd/yyyy)

1. ENROLLEE NAME

2. SOCIAL SECURITY NUMBER

3. DATE OF BIRTH

4. SEX

5. ARE YOU MARRIED?

M

F

YES

NO

(including ZIP Code)

6. HOME MAILING ADDRESS

I need to correct my address.

7. IF YOU ARE COVERED BY MEDICARE, CHECK ALL THAT APPLY

8. MEDICARE CLAIM NUMBER

The changes are indicated in item 6

A

B

D

9. ARE YOU COVERED BY INSURANCE OTHER THAN MEDICARE?

YES, indicate in item 10 below.

NO

10. INDICATE THE TYPE(S) OF OTHER INSURANCE

NAME OF OTHER INSURANCE

POLICY NUMBER

An FEHB self and family enrollment covers all eligible family members. No

person may be covered under more than one FEHB enrollment.

FEHB

TRICARE

OTHER

Dependents' Information. Fill in the applicable information in the blocks below. For additional family members please use a separate sheet of paper. Relationship Codes are: 01. Spouse;

19. Child under age 26; 09. Adopted child; 17. Step child; 10. Eligible foster child; 99. Disabled child age 26 or older who is incapable of self-support because of a physical or mental

disability that began before his/her 26th birthday.

(last, first, middle initial)

(mm/dd/yyyy)

11. NAME OF FAMILY MEMBER

12. SOCIAL SECURITY NUMBER

13. DATE OF BIRTH

14. SEX

15. RELATIONSHIP CODE

M

F

(if different from enrollee)

16. ADDRESS

17. IF YOU ARE COVERED BY MEDICARE, CHECK ALL THAT APPLY 18. MEDICARE CLAIM NUMBER

A

B

D

19. ARE YOU COVERED BY INSURANCE OTHER THAN MEDICARE?

YES, indicate in item 20 below.

NO

20. INDICATE THE TYPE(S) OF OTHER INSURANCE

NAME OF OTHER INSURANCE

POLICY NUMBER

An FEHB self and family enrollment covers all eligible family members. No

person may be covered under more than one FEHB enrollment.

TRICARE

OTHER

FEHB

(if home address is different from enrollee's)

(if home address is different from enrollee's)

21. EMAIL ADDRESS

22. PREFERRED TELEPHONE NUMBER

(last, first, middle initial)

(mm/dd/yyyy)

23. NAME OF FAMILY MEMBER

24. SOCIAL SECURITY NUMBER

25. DATE OF BIRTH

26. SEX

27. RELATIONSHIP CODE

M

F

(if different from enrollee)

28. ADDRESS

29. IF YOU ARE COVERED BY MEDICARE, CHECK ALL THAT APPLY 30. MEDICARE CLAIM NUMBER

D

B

A

31. ARE YOU COVERED BY INSURANCE OTHER THAN MEDICARE?

YES, indicate in item 32 below.

NO

32. INDICATE THE TYPE(S) OF OTHER INSURANCE

NAME OF OTHER INSURANCE

POLICY NUMBER

An FEHB self and family enrollment covers all eligible family members. No

person may be covered under more than one FEHB enrollment.

FEHB

TRICARE

OTHER

(if home address is different from enrollee's)

(if home address is different from enrollee's)

33. EMAIL ADDRESS

34. PREFERRED TELEPHONE NUMBER

SECTION II - FEHB Plan You Are Currently Enrolled In

Section III - FEHB Plan You Are Changing to

1. PLAN NAME

2. ENROLLMENT CODE

1. PLAN NAME

2. ENROLLMENT CODE

SECTION IV - Signature

WARNING: Any intentionally false statement in this application or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than $10,000 or

imprisonment of not more than 5 years, or both. (18 U.S.C. 1001.)

(do not print)

(mm/dd/yyyy)

1. YOUR SIGNATURE

2. DATE

3. EMAIL ADDRESS

4. PREFERRED TELEPHONE NUMBER

(

)

DR25A (revised 10/15)