CalPERS Health Benefits Program Forms

Choose a form below.

• Electronic Fund Transfer (EFT Credit) Authorization Agreement (PDF, 61 KB)
• Health Benefit Plan Enrollment (HBD-12) (PDF, 78 KB)
• Instructions for Using Health Benefit Plan Enrollment Form (PDF,136 KB)
• Declaration of Health Coverage Form (HBD-12A) (PDF, 748 KB)
• Direct Payment Authorization (HBD 21) (PDF, 36 KB)
• COBRA Beginning and Ending Dates (Starting January 2008 and ending December 2012) (PDF, 15 KB)
• DEV Employer Exemption Request (PDF, 49 KB)