Standard Form 2809 - Health Benefits Election Form printable pdf download

Form Approved:

Health Benefits Election Form

OMB No. 3206-0160

Item 8.

If you have Medicare, enter your Medicare Claim Number.

Uses for Standard Form (SF) 2809

This number is on your Medicare Card.

Use this form to:

•

Enroll or reenroll in the FEHB Program; or

Item 9.

If you are covered by other health insurance, either in your

name or under a family member’s policy, check yes and

•

Elect not to enroll in the FEHB Program (employees only); or

complete item 10.

•

Change your FEHB enrollment; or

Item 10. Provide the information requested on any other health

•

Cancel your FEHB enrollment; or

insurance that covers you. An FEHB Self and Family

enrollment covers all eligible family members. If you or a

•

Suspend your FEHB enrollment (annuitants or former spouses

family member is covered under another FEHB enrollment,

only).

check the FEHB box and

. Contact your Human Resources

office or retirement system immediately as this is a dual

Who May Use SF 2809

coverage situation. Examples of how this could occur are:

1. Employees eligible to enroll in or currently enrolled in the FEHB

•

You are enrolling in an FEHB Self Only plan while

Program, including temporary employees eligible under 5 U.S.C.

your spouse has an FEHB Self and Family plan (which

8906a. Employees automatically participate in premium

automatically covers you).

conversion unless they waive it, see page 7.

•

You are enrolling in an FEHB Self and Family plan

2. Annuitants in retirement systems other than the Civil Service

while your spouse has an FEHB Self Only or Self and

Retirement System (CSRS) or Federal Employees Retirement

Family plan.

System (FERS), including individuals receiving monthly

compensation from the Office of Workers’ Compensation

•

You are an employee under age 26 and have no

Programs (OWCP).

dependents. You are enrolling in your own FEHB plan

while you are covered under your parent’s FEHB Self

Note: Civil Service Retirement System (CSRS) and Federal

and Family plan.

Employees Retirement System (FERS) annuitants and former

spouses and children of CSRS/FERS annuitants -- Do not use

•

You are an annuitant who is reemployed in the Federal

this form. Instead, use form OPM 2809, which is available at

government. You are enrolling in an FEHB plan as an

, or call the Retirement Information Office

employee while you are covered under your own or a

toll-free at 1-888-767-6738.

family member’s FEHB plan.

No person may be covered under more than one FEHB

3. Former spouses eligible to enroll in or currently enrolled in the

enrollment. However, in certain unusual circumstances, your

FEHB Program under the Spouse Equity law or similar statutes.

agency may allow you to enroll in order to:

4. Individuals eligible for Temporary Continuation of Coverage (TCC)

under the FEHB Program, including:

•

Enable an employee under age 26 who is covered under

a parent’s Self and Family FEHB enrollment to enroll in

•

Former employees (who separated from service);

FEHB to cover his or her own spouse and/or child;

•

Children who lose FEHB coverage; and

•

Enable an employee under age 26 who is covered under

a parent’s Self and Family FEHB enrollment, but lives

•

Former spouses who are not eligible for FEHB under item 3

outside his or her parent’s HMO service area, to have

above.

FEHB coverage;

•

Instructions for Completing SF 2809

Enable an employee who separates or divorces to enroll

in FEHB to cover family members who move outside

Type or Print. We have not provided instructions for

the HMO service area of the covering FEHB Self and

those items that have an explanation on the form.

Family enrollment.

Part A — Enrollee and Family Member Information

In these unusual situations, each enrollee must notify his

You must complete this part.

or her plan as to which family members are covered under

which enrollment. See Dual Enrollment information on

Item 2.

See the Privacy Act and Public Burden Statements on page 5.

page 4.

Item 5.

If you are separated but not divorced, you are still married.

Item 7.

If you have Medicare, check which Parts you have, including

prescription drug coverage under Medicare Part D.

Standard Form 2809

Revised August 2011

Previous edition is not usable

Standard Form 2809 - Health Benefits Election Form

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