Completing the retiree forms

Find out which forms you need and how to complete them. 

Follow the steps below to enroll in PEBB retiree coverage for the first time, or make changes to your existing PEBB enrollment if you're within 60 days of a qualifying event (like the birth of a child, marriage, or divorce).

New enrollment or enrolling after deferral

Step 1: Visit compare medical plans to compare retiree plan choices and make sure you live in the plan's service area.

Step 2: Locate your plan choice under Form(s) to complete and complete the appropriate form(s). Be sure to include all eligible family members you wish to enroll.

Step 3: Submit the completed form(s) to the PEBB Program as instructed on the form(s) within the deadline provided.

Changing plans, or adding or removing family members

Step 1: Fill out the Retiree Coverage Election/Change Form (Form A).

Step 2: If you are changing medical plans, visit compare medical plans to compare retiree plan choices and make sure the plan you have selected is available in your area.

Step 3: Locate your plan choice under Form(s) to complete and complete the appropriate form(s).

Also complete a Medicare Advantage Plan Disenrollment Form (Form D) if you or a covered dependent are:

  • Enrolled in a Medicare Advantage plan and changing to a plan that is not a Medicare Advantage plan, or
  • Removing a Medicare eligible dependent.

Step 4: Submit the completed form(s) to the PEBB Program as instructed on the form(s).

Deferring enrollment in PEBB benefits when you retire (before you enroll)

Step 1: Fill out all sections marked required in the Retiree Coverage Election/Change Form (Form A), including:

  • Section 1 (Subscriber Information and Enrollment Election/Change),
  • Section 9 (Signature), and if applicable,
  • Section 7 (Retiree Term Life Insurance Election) and Section 8 (Payment Authorization).

Step 2: Submit the completed form to the PEBB Program as instructed on the form. The PEBB Program must receive the form no later than 60 days after your employer-paid coverage, COBRA coverage, or continuation coverage ends.

Deferring or cancelling enrollment in PEBB benefits (after you are enrolled)

Step 1: Fill out all sections marked required in the Retiree Coverage Election/Change Form (Form A), including:

  • Section 1 (Subscriber Information and Enrollment Election/Change), and
  • Section 9 (Signature).

Step 2: If you or a covered dependent are cancelling enrollment in a Medicare Advantage plan, also complete a Medicare Advantage Plan Disenrollment Form (Form D).

Step 3: Submit the completed form(s) to the PEBB Program as instructed on the form.

Forms to complete

Depending on your plan choice, complete the appropriate form(s) listed below to enroll in or make changes to a plan.

To enroll in, defer, or make changes to these plans: Use
  • Kaiser Permanente WA (formerly Group Health), Classic, CDHP, Original Medicare, SoundChoice, or Value
  • Kaiser Permanente NW Classic* or CDHP*
  • Uniform Medical Plan (UMP) Classic, CDHP, UMP Plus-PSHVN, or UMP Plus-UW Medicine ACN

Form A only

To enroll in or make changes to these plans: Use
  • Kaiser Permanente WA (formerly Group Health) Medicare Advantage
  • Kaiser Permanente NW Senior Advantage
Forms A and C
  • Medicare Supplement Plan F, administered by Premera Blue Cross
Forms A and B
To cancel, defer, or change from these plans: Use
  • Kaiser Permanente WA (formerly Group Health) Medicare Advantage
  • Kaiser Permanente NW Senior Advantage
Forms A and D

*Kaiser Foundation Health Plan of the Northwest, with plans offered in Clark and Cowlitz counties in WA, and the Portland, OR area.

If enrolling a: Complete this form:
Non-qualified tax dependent Declaration of Tax Status
Dependent child with a disability Certification of Dependent with a Disability
Extended (legal) dependent child Extended Dependent Certification

Mail your forms

Complete, sign, and date the form(s) and mail them to:

Washington State Health Care Authority
PEBB Program
P.O. Box 42684
Olympia, WA 98504-2684

If you're sending payment with your form(s), please enclose your check or money order payable to Health Care Authority and mail to:

Washington State Health Care Authority
P.O. Box 42695
Olympia, WA 98504-2695

Things to remember

  • If you or any covered dependents haven’t sent us a copy of your Medicare card(s), send it along with your form(s).
  • If you are not enrolled in Medicare Part A and Part B, you must provide copies of documents that prove eligibility of any dependents you wish to enroll.
  • If you’re adding a state-registered domestic partner or a state-registered domestic partner’s child to your coverage, you must also complete and submit the Declaration of Tax Status form. Proof of their eligibility is also required. A list of acceptable documents is on the next page.
  • If you’re adding a state-registered domestic partner to your coverage and completing Form C, fill out the “spouse” sections of the form for your partner.
  • Please use black ink to complete the form(s).