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Employee Enrollment/Change Form (PEBB) 2023

Use this form to enroll in or make changes to PEBB Program benefits for you or your dependents.

50-0400
Form

Employee Enrollment/Change Form Medical Only (PEBB) 2023

Use this form to enroll in or make changes to PEBB Program benefits for you and your dependents if your employer offers PEBB Program medical coverage only.

52-0030
Form

Free or low-cost health care
- I need medical, dental, or vision care
  - Find Apple Health benefits & services
  - Other Apple Health programs
  - Am I eligible?
  - Learn about my coverage
  - Use my coverage
  - Manage my coverage
- I need behavioral health support
  - Mental health
  - Substance use
  - Prenatal, children & young adults
  - American Indians & Alaska Natives
    - Behavioral health services for American Indians & Alaska Natives (AI/AN)
  - Recovery support services
  - Prevention
    - Substance use disorder prevention & mental health promotion
- I help others apply for & access Apple Health
  - Apple Health Eligibility Manual
  - Additional tools
  - Stakeholder training & education
- Quick links
- Contact Apple Health (Medicaid)
- News
Employee & retiree benefits
- Public employees
  - Find benefits
  - Explore costs
  - Determine eligibility
  - Learn how to enroll
  - For survivors
  - Manage benefits
  - Get help
- School employees
  - Find benefits
  - Explore costs
  - Determine eligibility
  - Learn how to enroll
  - For survivors
  - Manage benefits
  - Get help
- Retirees
  - Find benefits
  - Explore costs
  - Determine eligibility
  - Learn how to enroll
  - Learn how & why to defer
  - For survivors
  - Manage benefits
  - Get help
- PEBB Continuation Coverage
  - Find benefits
  - Explore costs
  - Determine eligibility
  - Learn how to enroll
    - For newly eligible members
    - Verify & enroll my dependents
  - For survivors
  - Manage benefits
  - Get help
- SEBB Continuation Coverage
  - Find benefits
  - Explore costs
  - Determine eligibility
  - Learn how to enroll
    - For newly eligible members
    - Verify & enroll my dependents
  - For survivors
  - Manage benefits
  - Get help
- Quick links
- Contact us
- PEBB news
- SEBB news
Billers, providers & partners
- Prior authorization, claims & billing
  - Getting started
  - Submit prior authorization (PA)
    - Step-by-step guide for prior authorization (PA)
    - Pharmacy prior authorization
  - Submit claims
    - Provider billing guides & fee schedules
    - Hospital rates & reimbursement
- Program information for providers
- Become an Apple Health provider
  - Learn how to enroll
  - What's next
    - Find next steps for new Medicaid providers
  - For existing medicaid providers
    - Update my provider information
    - Revalidation
- Learn ProviderOne
  - Getting started
    - How do I access ProviderOne?
  - Training materials
- Quick links
- Contact us
- News
About HCA
- Programs & initiatives
- Who we are
  - About us
  - Boards, committees & collaborations
  - Health innovation
- Data & reports
- Other administrative activities
  - Medicaid-related
  - Government transparency
    - Gender identity information
    - Public disclosure request
  - Community services
    - Disaster outreach
    - Voter registration
- News
  - Find out what's new
  - Follow HCA on social media
    - Facebook
    - Twitter
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    - Medium
    - HCA Connect
    - LinkedIn
    - YouTube
  - For the press
    - Visit our press room
  - HCA Connect
- Quick links
- Contact HCA
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