Denver Public Schools

Benefits Change Form

FAX# 720-423-2505

Effective Date _____/_____/______(1st of next month)

Status Change Explanation: This form and documentation must be received within 30 days of change or 60 days for Medicaid/CHIP participant’s enrollment or loss of coverage.

  • Job status change (if employee or spouse increases/decreases work hours resulting in a change in benefit eligibility, spouse’s loss or gain of employment, enrollment in spouse’s plan during his or her job’s open enrollment period) [attach copy of letter for proof]
  • Marriage (if adding spouse/dependent stepchildren or moving to new spouse’s insurance) [attach marriage license]
  • Divorce [attach final court paperwork]
  • Birth [attach copy of proof of live birth – either birth certificate or hospital issued documentation]
  • Adoption (if adding dependent through adoption/ guardianship) [attach court paperwork]
  • Death [attach copy of death certificate]
  • Enrollment in Medicare [attach copy of Medicare Card]
  • Enrollment in Medicaid or CHIP [attach copy of enrollment verification]
  • Return from unpaid leave
  • Increase/Decrease Health Savings Account Election (HSA) at any time, MUST be enrolled in a CDHP plan

Employee Information______

Last Name______First______MI______

Emp ID# ______Date of Birth_____/_____/______

Address ______City______State_____Zip______

Home Phone ______Work Phone______

Coverage Changing to: ______

  • Employee Only
  • Employee & Spouse (includes domestic partner or common-law spouse with affidavit)
  • Employee & Child(ren)
  • Employee & Family
  • Waive Coverage

Coverage Plan(s) to be Changed: ______

Revised 7/1/2013

Denver Public Schools

Benefits Change Form

FAX# 720-423-2505

Effective Date _____/_____/______(1st of next month)

  • Kaiser Deductible HMO
  • Kaiser CDHP
  • CIGNA Select HMO
  • CIGNA OAP (POS)
  • CIGNA CDHP
  • Delta Dental Premier
  • Delta Dental EPO
  • Vision Service Plan
  • Healthcare Flexible Spending Account

Amt. _____per month (increase/decrease)

  • Dependent Care Spending Account

Amt. _____per month (increase/decrease)

  • Health Savings Account (HSA)

Amt. _____per month (increase/decrease)

Revised 7/1/2013

Denver Public Schools

Benefits Change Form

FAX# 720-423-2505

Effective Date _____/_____/______(1st of next month)

Add these Members or Delete these Members

Last Name / First / MI / SS# / Birthdate / Sex
M/F
Employee:
Spouse:
Dependent:
Dependent:
Dependent:

I elected after-tax premium deduction status prior to this change request and want these benefits to also be after-tax.

Acceptance and Authorization

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any misrepresentation of information may void membership benefits retroactively to the date benefits began. I have attached valid documentation to support any change in benefits that I am requesting. I understand that I can only change from pre-tax to after-tax premium deduction status during annual open enrollment for July 1 effective date. I further understand that it is my responsibility to check my payroll stubs through Employee Self Service to verify that my requested changes are made properly after the effective date of the change (monthly thereafter) and report any discrepancies to HR Connect, 720-423-3900, immediately upon discovery. DPS will not refund premiums in excess of the amount the insurance carrier is willing to reimburse or Flex $$ beyond 2 prior months.

Signature of Employee ______Date ______

Revised 7/1/2013