Transcription of Health Benefits Enrollment Form
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Health Benefits Enrollment Form
This form is to be used by probationary/permanent new hire employees who are eligible for the below medical, dental and vision coverage Medical, Dental, and Vision Benefits Premium Contributions Kern Legacy Select Uses Kern Medical hospital and County-owned, Kern Health Care Network providers and contracted facilities. Kern Legacy Health Plan Network Plus Uses Kern Medical hospital and County-owned, Kern Health Care Network for both EPO and Plus tiers (includes Adventist Health Bakersfield Medical Center).County of Kern EPO Uses GemCare and Delano Medical Group providers with Dignity Health hospital and Permanente Uses Kaiser Permanente contracted physicians and facilities including Adventist Health Bakersfield Medical Center.
REQUIRED DOCUMENTATION FOR DEPENDENT ENROLLMENT ALL Dependents: Social Security number must be listed on form. Spouses/ Domestic partners: A copy of a marriage certificate/registration form must accompany the enrollment form.
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