Eligibility Forms
Eligibility Forms should be mailed to:
State Health Plan Benefit
Post Office Box 1990
Atlanta, Georgia 30301-1990
Appeals
Administrative Review Form - updated 4/2/09
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 4/2/09
Over Age Dependent Coverage
Dependent Student Status Information - Updated 4/1/2009
Use this form 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 valid identification card showing the student as a covered dependent.
Surcharges Spousal and Tobacco
Please refer to the Health Plan Information for details of the SHBP Policy concering the Tobacco and Spousal Surcharges.
Spousal Surcharge Form - Updated 11/12/09
Use this form to remove a spousal surcharge when spouse is not eligible or is enrolled for health coverage through their employer.Non-Tobacco Users Affidavit Form - Updated 11/12/09
Use this form to remove tobacco surcharge if you and all covered dependents are non-tobacco users.Tobacco Users Cessation Policy and Classes - updated 11/12/09
Tobacco Cessation Affidavit Form - updated 11/12/09
Decline or Discontinue Coverage
Declination of Health Benefit Coverage - updated 1/15/10
Use this form when an employee declines coverage upon employment or is ineligible for coverage due to employment status. (e.g., part-time employee).Discontinuation of Health Benefit Coverage - updated 1/21/10
Retiree Discontinuation Form
Please contact the SHBP Call Center at 404-656-6322 or 1-800-610-1863 for further information.
NOTE: if you discontinue you will NOT be eligible to re-enroll for any coverage under the State Health Benefit Plan.
Enroll or Update Coverage
If you experience a qualifying event, you may be able to make changes for yourself and your dependents, provided you request the change within 31 days of the qualifying event. For a complete list of qualifying events refer to the 2009 Decision Guide. Request must be made within 31 days. DO NOT HOLD FORM FOR VERIFICATION DOCUMENTATION.
2010 EE Enrollment/Transfer Form (SHBP 66-091) - Updated 1/21/10
This form is to be used only for New enrollees or New employees hired or enrolling after 12/31/08.Change and Miscellaneous Update Form - Updated 1/21/10
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.Retirement/Surviving Spouse Form - Updated 1/21/10
This form should be used when a retiring member elects to continue coverage through retirement or to change option or type of coverage after retirement.
Employer Use Only
Forms Transmittal Sheet - updated 4/1/09
This form 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.
Notification of Return from Leave Without Pay
Use this form to notify the SHBP when a member returns to work after being on an approved leave without pay.
Other
Release of Information to Personal Representative Form
Use this form to release personal health information to someone other than the patient.
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