Personnel Services

Current Employees

• Active Employee Enrollment Form
  
• Special District Employee Enrollment Form
• Waiver of Employer Coverage Affidavit - 2023
  
• Waiver of Employer Coverage Affidavit - 2022
• Active 2023 MyBenefits Summary​
• ​Active 2022 MyBenefits Summary​
• Special District 2023 MyBenefits Summary​
• Special District 2022 MyBenefits Summary
  

Kaiser Permanente (KP)

• HMO Evidence of Covera​ge
  
• High Deductible HMO Evidence o​f Coverage
• Kaiser HMO SBC
  
• Kaiser HDHP HMO SBC​

Sutter Health Plus (SHP)

• HMO Evidence of Coverage
  
• High Deductible HMO Evidence o​f Coverage   
  
• Evidence of Coverage - Infertility Rider
• ​​Sutter HMO SBC
• ​​Sutter HDHP HMO SBC​
  
• HMO Infertility Rider 2022
  
• HMO Chiro and Acupuncture Rider 2022
  
• HMO Chiro and Acupuncture Schedule of Benefits 2022​

• Evidence of Coverage​
  
• Infertility Benefit
• WHA HMO SBC​
• WHA HDHP HMO SBC
  
• Employee only
• Family​
  

Vision Service Plan (VSP) 

• VSP Vision Care
• Coverage Details

Health Savings Accounts (HSA)

• HSA Authorization Form
  
• Optum Designation of Beneficiary
  
• Optum Rollover Form
• Health Equity HSA Rollover Form
• Health Equity HSA Beneficiary Designation

Flexible Spending Accounts (FSA)

• FSA Claim Form
• Day Care Reimbursement Claim Form
• Orthondontia Reimbursement Claim Form
• Flex Plan Summary​

Delta Dental (Dental)

• Employee Dental Plan booklet
  

Life Insurance

• Explore Your Benefits - Group Term Life Insurance
  

Critical Illness

• Explore Your Benefits - Critical Illness​

Retiree Health Savings Plan (RHSP)

• Retiree Health Savings Plan Document
  
• Employee Change Form​

529 College Savings Plan

• Direct Deposit Allocation Form​​
  

​​

Retirees

• ​​​Retiree 2023 MyBenefits Summary
  
• Retiree 2022 MyBenefits Summary
  
• Retiree Enrollment Form
• Retiree Medical Administrative Policy​

Medicare Enrollment Forms

(Required in addition to the County form when enrolling in or switching between a Medicare Plan)

• Kaiser Senior Advantage Applicatio​n​​
  

Medicare Disenrollment Forms

(Required in addition to the County form when dis-enrolling from or switching between a Medicare plan) 

• Kaiser Senior Advantage Disenrollment Form 

Kaiser Permanente (KP)

• HMO Evidence of Covera​ge
  
• High Deductible HMO Evidence o​f Coverage
• Senior Advantage $15 Evidence o​f Coverage
• Senior Advantage $25Evidence o​f Coverage
• Kaiser HMO SBC
• Kaiser HDHP HMO SBC
  
• Summary of Benefits​
  
• Medicare Overview
  

• HMO Evidence of Coverage
  
• High Deductible HMO Evidence o​f Coverage   
  
• Evidence of Coverage - Infertility Rider  
  
• ​​Sutter HMO SBC
• ​​Sutter HDHP HMO SBC​
• HMO Infertility Rider 2022
• HMO Chiro and Acupuncture Rider 2022
• HMO Chiro and Acupuncture Schedule of Benefits 2022​

United HealthCare (UHC)

• HMO Evidence of Coverage
  
• PPO Evidence of Cove​rage
  
• HMO Plan Guide
  
• PPO Plan Guide​​
  

Western Health Advantage (WHA)

• Evidence of Coverage​
  
• Infertility Benefit
• WHA HMO SBC
• WHA HDHP HMO SBC
  
• Employee only
• Family​

Vision Service Plan (VSP) ​

• VSP Vision Care
  
• Coverage Details

Delta Dental (Dental)

• ​​​​​Basic Plan Coverage​
• Enhanced Plan Coverage
  

Retiree Health Savings Plan (RHSP)

• Claim Fo​rm
  
• Eligibility Form
  
• Direct Deposit Authorization Form​
  
• Decedent Information Form​