For the best experience filling out and submitting forms, please follow these instructions: These forms are posted here for schools and Family Welcome Center staff to share with families. The site navigation utilizes arrow, enter, escape, and space bar key commands. Need help or have questions? On this page, you'll find the forms you might need to enroll in a DOE public school. Read the McKinney-Vento Homeless Assistance Act on our New Students page. Which family members are affected by the change? RETIREE HEALTH BENEFITS ENROLLMENT AND CHANGE FORM JANUARY 2020-DECEMBER 2020 PERSONAL DATA PLEASE PRINT CLEARLY COMPLETED AND SIGNED ENROLLMENT FORMS MAY BE MAILED OR HAND-DELIVERED TO: Employee Benefits Division 301 W. Preston Street, Room 510 Baltimore, Maryland 21201 Hours of Operation: Monday - Friday 8:30 a.m. - 4:30 p.m. Guardian employer application is generated on a group specific basis. INSTRUCTIONS FOR THE SHBP LOCAL GOVERNMENT ACTIVE EMPLOYEE GROUP HEALTH BENEFITS ENROLLMENT AND/OR CHANGE FORM SECTION 1 – MEMBER INFORMATION – Complete entire section. h�bbd```b``z Evidence of Insurability Form - Life & Disability, COBRA - Election of Continued Coverage Form. endstream endobj startxref The Universal Enrollment/Change Form below may also be used. Tab will move on to the next part of the site rather than go through menu items. h�b``f``:����hz�01G��030�2�35(t��Hة���m[6w�� [�� f����r���`F1Z̀ɴH310Z�C����330�BD�fAt�,gc`9f�0 �W� Please note: Forms do NOT need to be notarized. Left and right arrows move across top level links and expand / close menus in sub levels. Fill out an enrollment change form and include a copy of the Social Security Card reflecting the name change. %%EOF ... Only the legal guardian can change the address of a minor. Students in temporary housing, as defined by the McKinney-Vento Homeless Assistance Act, are not required to submit documentation (including address, proof of date of birth, and immunization records) in order to participate in any admission process or enroll in school. DENTAL PPO PLANS Policy Form IP-DEN-16 ET. "���SA$G9�d��@$��- f���l 0�l�2���� ��,�"k΀��$�]���L@7���301�?��G I�� Guardian paper employee applications can be generated at the time of sale and customized based on the lines of coverage sold. Fill out, sign, and send your form directly from the app. 1199SEIU Funds 498 Seventh Avenue New York, NY 10018 (646) 473-9200 Download the form and and save it to your computer. 149 0 obj <>/Filter/FlateDecode/ID[<20BFAF9A3630C44F834512136C2D08C3>]/Index[128 54]/Info 127 0 R/Length 106/Prev 87777/Root 129 0 R/Size 182/Type/XRef/W[1 3 1]>>stream Contact your RBG Team for assistance in obtaining a customized form. endstream endobj 129 0 obj <. Read below to find out what you need to do to enroll. (Please list below.) Guardian Health: Claim Form for Participating Providers; Drug Exclusion Listing; Group Change Request & Beneficiary Update Form; Health Claim Form (Individual Member) Member Enrollment & Health History Questionnaire Form; Provider Application Form; Provider Authorisation for Cheque Collection 0 Affidavit of Emancipation -- French (Haiti), Affidavit of Emancipation -- French (France), Emergency Contact Card -- French (France), Home Language Identification Survey -- English, Home Language Identification Survey -- Spanish, Home Language Identification Survey -- Chinese, Home Language Identification Survey -- Bangla, Home Language Identification Survey -- Russian, Home Language Identification Survey -- Urdu, Home Language Identification Survey -- Arabic, Home Language Identification Survey -- French (Haiti), Home Language Identification Survey -- Korean, Home Language Identification Survey -- French (France), Kindergarten New Admit Questionnaire -- English, Kindergarten New Admit Questionnaire -- Spanish, Kindergarten New Admit Questionnaire -- Chinese, Kindergarten New Admit Questionnaire -- Bangla, Kindergarten New Admit Questionnaire -- Russian, Kindergarten New Admit Questionnaire -- Urdu, Kindergarten New Admit Questionnaire -- Arabic, Kindergarten New Admit Questionnaire -- French (Haiti), Kindergarten New Admit Questionnaire -- Korean, Kindergarten New Admit Questionnaire -- French (France), Multilingual Learners Parent Survey and Program Agreement Form -- English, Multilingual Learners Parent Survey and Program Agreement Form -- Spanish, Multilingual Learners Parent Survey and Program Agreement Form -- Chinese, Multilingual Learners Parent Survey and Program Agreement Form -- Bangla, Multilingual Learners Parent Survey and Program Agreement Form -- Russian, Multilingual Learners Parent Survey and Program Agreement Form -- Urdu, Multilingual Learners Parent Survey and Program Agreement Form -- Arabic, Multilingual Learners Parent Survey and Program Agreement Form -- French (Haiti), Multilingual Learners Parent Survey and Program Agreement Form -- Korean, Multilingual Learners Parent Survey and Program Agreement Form -- French (France), Parent Affidavit of Residency -- French (Haiti), Parent Affidavit of Residency -- French (France), Parent-Guardian-Student Ethnic and Race Identification - PSE -- English, Parent-Guardian-Student Ethnic and Race Identification - PSE -- Spanish, Parent-Guardian-Student Ethnic and Race Identification - PSE -- Chinese, Parent-Guardian-Student Ethnic and Race Identification - PSE -- Bangla, Parent-Guardian-Student Ethnic and Race Identification - PSE -- Russian, Parent-Guardian-Student Ethnic and Race Identification - PSE -- Urdu, Parent-Guardian-Student Ethnic and Race Identification - PSE -- Arabic, Parent-Guardian-Student Ethnic and Race Identification - PSE -- French (Haiti), Parent-Guardian-Student Ethnic and Race Identification - PSE -- Korean, Parent-Guardian-Student Ethnic and Race Identification - PSE -- French (France), Pre-K Language Needs Survey -- French (Haiti), Pre-K Language Needs Survey -- French (France), Provisional Admission Form -- French (Haiti), Provisional Admission Form -- French (France), Student Registration Form -- French (Haiti), Student Registration Form -- French (France), Third Party Statement of Residency -- English, Third Party Statement of Residency -- Spanish, Third Party Statement of Residency -- Chinese, Third Party Statement of Residency -- Bangla, Third Party Statement of Residency -- Russian, Third Party Statement of Residency -- Urdu, Third Party Statement of Residency -- Arabic, Third Party Statement of Residency -- French (Haiti), Third Party Statement of Residency -- Korean, Third Party Statement of Residency -- French (France), Sign the COVID testing consent form using your NYCSA account, Afternoon Parent Teacher Conferences: High Schools, Evening Parent Teacher Conferences: Middle Schools/District 75, Afternoon Parent Teacher Conferences: Middle Schools/District 75, District School Reopening Plan Submission to NYSED, If you're not the primary leaseholder or homeowner where you live, fill out the, If you're temporarily taking care of a student but are not their parent or guardian, fill out the, We speak your language! DENTAL HMO PLANS FLORIDA Policy Form IP-1-MDG-DHMO-FL-OFF-17 NEW YORK Policy Form IP-MDG-NY-FP-OFF-17 Products Underwritten by Managed Dental … For children entering grades 3-K through kindergarten in September 2020, please reach out to the program where you’ve accepted an offer regarding specific registration instructions. For the best experience, open the form using Adobe Reader. Any submission after this date may forfeit my right to enroll or make changes in the dental plan until the next open enrollment period unless I have a qualifying event. 128 0 obj <> endobj They can be done in person, faxed, mailed or e-mailed. Most forms are digitally accessible (optimized for screen readers) but some are not yet; we are working to provide updated accessible versions of all forms. If your home language is not English, be sure to request a, Download the Adobe Fill & Sign: Easy PDF Doc & Form Filler app for. The Universal Enrollment/Change Form below may also be used. I may elect/waive ANY or ALL optional plans as best meets my needs. If you need help or have comments or questions about this site, click here to contact us. Anytime Website Pre-Registration Form & Consent to Delivery of Electronic Materials. Contact your RBG Team for assistance in obtaining a customized form. Current Customers Customers who are currently enrolled in … Continue reading Open Enrollment 2020-KPIF-ACF-1 Page 3 of 5 325835347 KPWA 2020-C. For children entering grades 3-K through kindergarten in September 2020, please reach out to the program where you’ve accepted an offer regarding specific registration instructions. I understand that I must complete my Guardian application/change form by May 29, 2020. Enter and space open menus and escape closes them as well. If any form includes a section on notarization, just leave it blank. Each form is available in ten languages, and most forms are PDFs that can be filled out online. If there has been no change … AL. (For CA residents, it starts October 15, 2018 on your state exchange). Plan Holder Service & Support Quick Reference Guide, Supplemental Health - You Can't Predict but You Can Prepare, Will Prep Services Overview for Employees, Guardian Choice Affordable Dental Coverage Flyer, Dental Deductible, Maximum Accumulator and Maximum Rollover Reports, Online Provider Search Instructions - Dental, Online Provider Search Instructions - Vision, Disability & Absence Management - How Guardian LTD Can Protect Employees.

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