2017 Retiree Open Enrollment Forms

Kaiser Permanente

Kaiser Senior Advantage HMO
Enrollment Form
Enrollment Form - Spanish
Disenrollment Form

Blue Shield

Blue Shield 65 Plus (HMO) Medicare Advantage
Enrollment Form
Disenrollment Form
Blue Shield Medicare Rx Plan (PDP)
Enrollment Form


Please complete the County of San Bernardino Retiree Dental Plan Enrollment Form to enroll or make changes to coverage.

County of San Bernardino

Retiree Medical Plan Enrollment/Change Form
Retiree Dental Plan Enrollment/Change Form
Retiree Medical/Dental Plan Cancellation Form
Retiree Disabled Dependent Certification

Retiree Medical Trust Fund

Medical Expense Claim Form
 Recurring Individual Premium Request Form

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