Side 1 of Form

Your SSN/SSN of Deceased PERA Member/Retiree

Print your Social Security number inside the boxes provided. If you are not the PERA member, print the Social Security number for the deceased PERA member or retiree in the second row of boxes.

Complete your full name, date of birth, and daytime telephone number.

Signature

Sign the form. By doing so you are certifying that you have read the PERACare 2010 Health Benefits Program Medicare Coverage booklet and are agreeing to the terms and conditions of the PERACare program listed in the Signature Certification box.

Effective Date

This is the date that you want health care coverage under PERACare to become effective.

If you are not enrolling during open enrollment, the effective date should coincide with the date your prior coverage ends or the date you become Medicare-eligible. If the date you want coverage to be effective is different from your retirement effective date, you may have to complete a Certification of Previous Health Care Coverage form (see the PERACare Enrollment Eligibility Chart for details).

Spouse Enrollment Information

Complete this section if you want to enroll your spouse in any of the plans (health, dental, or vision) available through PERACare.

Medicare Information

Complete this section to provide information on what types of Medicare coverage you and your spouse have (or have applied for). Write your Medicare number (printed on your Medicare card) on the form and send a photocopy of the card(s) to PERA.

Important Additional Medical Questions

If you are enrolling in one of the Medicare HMO plans (Kaiser Permanente, Rocky Mountain Health Plans, or Secure Horizons), you will not have to complete the carrier's Medicare plan application by answering "Yes" or "No" to the questions listed. If you answer "Yes" to any of the questions, PERA may contact you for more information.

Side 2 of Form

Health Plan Selection

Select your coverage level (who you want to enroll in a health plan). If you are enrolling dependent child(ren) who have Medicare, make sure you complete the Dependent Child(ren) Enrollment Information section of the form. (If you are enrolling a spouse or children who do not have Medicare, you should complete the PERACare Combination Coverage Premium Information/Enrollment Form rather than this Medicare form. Combination premiums are different from Medicare premiums and can also be found in the form.)

Select the plan in which you are enrolling. Information about each plan, including premiums, is included in the PERACare 2010 Health Benefits Program Medicare Coverage booklet.

If you are enrolling in Rocky Mountain Health Plans: You must select a primary care physician by completing the provider code section. Provider codes can be found on the provider directory page.  You may also call Rocky Mountain Health Plans at 1-888-281-0720 for provider codes. If you do not complete a provider code, Rocky Mountain Health Plans will send you an ID card without a primary care physician selection, which may delay your ability to access health care services.

If you are enrolling in Secure Horizons: You must select a primary care physician by completing the provider code section. Provider codes can be found on the provider directory page.  You may also call Secure Horizons at 1-800-610-2660 for provider codes. If you do not complete a provider code, Secure Horizons will assign a provider to you.

Dental Plan Selection

Select your coverage level (who you want to enroll in a dental plan). If you are enrolling dependent child(ren), make sure you complete the Dependent Child(ren) Enrollment Information section of the form.

Select the dental plan in which you are enrolling. Information about each plan, including premiums, is included in the PERACare 2010 Health Benefits Program Medicare Coverage booklet.

If you are enrolling in CIGNA Dental HMO: You must select a dentist for yourself as well as for your spouse and child(ren) (if applicable) by completing the provider code section. Provider codes can be found on the provider directory page. You may call CIGNA Dental at 1-877-635-PERA (7372) for provider code(s). PERA cannot complete your enrollment if you do not provide this information.

Vision Plan Selection

Select your coverage level (who you want to enroll in a vision plan). If you are enrolling dependent child(ren), make sure you complete the Dependent Child(ren) Enrollment Information section of the form.

Select the vision plan in which you are enrolling. Information about each plan, including premiums, is included in the PERACare 2010 Health Benefits Program Medicare Coverage booklet. If you select a coverage level and do not select a plan here, you will be enrolled in VSP PPO#1.

Dependent Child(ren) Enrollment Information

Complete this section if you are enrolling dependent child(ren) who have Medicare coverage in any of the plans (health, dental, or vision).