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2022 Retiree Election Form (Form A)

1211 HCA 51-4031 (10/21)A2022 PEBB Retiree Election Form (form A)Complete this form to enroll in or defer (postpone) enrollment in PEBB Retiree insurance coverage. If you wish to make a change to an existing Retiree account, please use the PEBB Retiree Change Form (form E). All forms and documents mentioned, and a self-paced tutorial about how to complete this form, are available on HCA s website at to read and sign Section 7. To enroll dependents, fill out Section 8. This form replaces all Retiree enrollment/change forms submitted in the past.

is eligible for Medicare, they must enroll and stay enrolled in Part A and Part B to keep PEBB retiree health plan coverage. They are in the process of enrolling in Medicare Part A and Part B. They will submit proof after they receive their entitlement letter or Medicare cards. 1 This field is required for health care services.

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