Transcription of SFHSS ENROLLMENT APPLICATION: CITY & …
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SFHSS ENROLLMENT APPLICATION: CITY & …
YOUR PERSONAL INFORMATION email AddressHome / Cell Telephone NumberWork Telephone NumberSFHSS ENROLLMENT APPLICATION: city & county OF SAN FRANCISCO EMPLOYEE FOR JANUARY DECEMBER 2018 PLAN YEARYou must submit a completed ENROLLMENT application and submit any required documentation to the San Francisco Health Service System ( SFHSS ) within 30 days of your initial benefits eligibility date or qualified change in family status. Refer to your Benefits Guide or visit for more details. Signature: Date Signed: CHOOSE YOUR MEDICAL PLAN (includes Basic VSP)CHOOSE YOUR DENTAL PLANBlue Shield Trio HMO1 Delta Dental PPOBlue Shield Access+ HMO1 UnitedHealthcare Dental DMO11 To enroll in an HMO/DMO Plan, you must live in an area serviced by the HMO/DMO.
YOUR PERSONAL INFORMATION email Address Home / Cell Telephone Number Work Telephone Number SFHSS ENROLLMENT APPLICATION: CITY & COUNTY …
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