Eligibility Forms

The forms listed below are associated with the eligibility function of the SHBP.

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SHBP 66-003	Request to Continue Health Benefits During Leave of Absence Without Pay should be used when a member is placed on approved leave of absence without pay and wishes to continue the coverage on a direct pay basis. Any time a member is not receiving pay but is not terminated from employment, he/she must be reported as on "leave without pay." The member may continue health coverage by paying the appropriate premium directly to the SHBP for the period of approved absence.
SHBP 66-004	Declination of Health Benefit Coverage should be used when an employee declines coverage upon employement or is ineligible for coverage due to employment status. (e.g., part-time employee).
SHBP 66-005	Disability Certification must be submitted with the request to continue health benefits during a leave of absence without pay due to a disability, including disability for the use of family leave (FMLA).
SHBP 66-010	Forms Transmittal Sheet is used as a control document that should be placed on top of any forms submitted and for submitting any coverage terminations to the SHBP.
SHBP 66-082	Dependent Student Status Information should be used to update the status of a dependent child who is over the age of nineteen for coverage as a fulltime student. An update is required every twelve months if the member desires to keep a vaild identification card showing the student as a covered dependent.
SHBP 66-088	Retiree Discontinuation Form
SHBP 66-089	Discontinuation of Health Benefit Coverage
SHBP 66-090	Membership Form/Miscellaneous Update Form - Must be completed by each eligible employee who wishes to enroll or change coverage option or type in any option offered by the SHBP. This form should be used for updating information such as address, or adding or deleting dependents to an existing family contract with the SHBP. Membership Form/Miscellaneous Update Form (2007)
SHBP 66-092	Retirement/Surviving Spouse Form should be used when a retiring member elects to continue coverage through retirement or to change option or type of coverage after retirement.
SHBP 66-093	Notification of Return from Leave Without Pay should be used to notify the SHBP when a member returns to work after being on an approved leave without pay.
SHBP 66-097	Material Orders Form - Use this form to request State Health Benefit Plan materials. - Updated 11/29/07
	Release of Information to Personal Representative Form should be used to release personal health information to someone other than the patient.
	FY 2006 Tobacco Cessation Programs Overview - Updated 1/5/06
	FY 2008 SHBP Tobacco Cessation Affidavit
	FY 2008 Kaiser Permanente Tobacco Cessation Affidavit
	Approved Tobacco Cessation Program Listings - Updated 3/6/08
	Disabled Dependent Questionnaire
	Administrative Review Form - Updated 5/11/07 This form should be used after contacting Member Services and requesting a telephone review within 90 days of the eligibility denial. The administrative review form is used as the second level of appeal under the plan and must be filed within 90 days of the denied action concerning your eligibility.
	Formal Appeal Form - Updated 5/11/07 This form should be used after the telephone review and administrative reviews are completed. The formal appeal must be filed within 60 days of the administrative review response. The formal appeal is the final step of the appeal process.