The CalPERS mailing of Open Enrollment Health Plan Statements was done on Thursday August 19th, 2010. If you did not receive your Health Plan Statement, please call CALPERS toll free at 888-225-7377.
NOTICE: These copies of the Blue Shield 2006 Combined Evidence of Coverage and Disclosure Form is being provided for your convenience. Blue Shield of California takes no responsibility for the information contained in this document on the Intranet. Please note that the Combined Evidence of Coverage and Disclosure Forms will be or have been provided to you in a printed copy format by Blue Shield of California and such printed copy is the official disclosure form required by the California Health and Safety Code.
Please complete only the highlighted portions of the form. To add a new dependent, please put an "A" in the Action Code column (highlighted on the form) to the left of the new dependent's name.
To delete a dependent from your medical plan, put a "D" in the Action Code column to the left of the name of the dependent you wish to delete from your plan.
