Public Employees Retirement System

Enrollment Request Form Instructions

You must complete all questions on pages 1-4 of the Enrollment Request Form.

Section A

  • Provide the effective date that you are requesting PHIP coverage to start. It must be the 1st of the month. If you are enrolling in PHIP as a new retiree, verify when your employer-coverage will be ending to prevent coverages from overlapping. Enrollments received after the requested effective date will become effective the first of the next month as long as it is within the applicable grace period.
  • Fill out all of the information related to the PERS retiree.
  • List all dependents that will be enrolled under the PHIP coverage with the retiree. If a non-PERS dependent is already enrolled you will want to include them so that they can be matched up with your enrollment. Certain documents may be required to enroll your dependent, so make sure that documents are provided as required.
    • Birth certificate for dependents under age 26
    • Marriage certificates for spouses with a different last name than the retiree
    • Affidavit of Domestic Partnership and most recent tax filings for dependent domestic partner
  • Choose the enrollment opportunity you are experiencing to enroll in PHIP
    • If making a change at plan change choose mark the plan change box that lists which benefits that you are changing to
    • A Termination form must also be submitted with a plan change


Section B

  • Fill out the Medicare information for all individuals that are eligible for Medicare. All must be enrolled both Medicare Parts A and B and a copy of the Medicare card or a Letter of Entitlement must be provided for processing to be completed


Section C

  • Choose the medical plan from the available plans within your service area
    • If you are Medicare eligible, you must enroll in one of the available Medicare plans
    • If you are Medicare due to ESRD or ALS you are limited to the Medicare plans you may choose. The Moda Supplement plan is available to all, but you may only enroll in one of the Advantage plans if you were previously covered under the same insurance plan immediately preceding enrollment into PHIP.
    • You can choose from either a Core Value or a Select Value plan. Once you are enrolled in a Select Value plan you may not change to a Core Value plan, even during plan change.


Section D

  • If you are enrolling in dental you will want to choose either Delta Dental of Oregon or Kaiser dental
    • You must be within the Kaiser service area to choose Kaiser
    • You may select either dental, regardless of the medical plan you choose, as long as you live within the appropriate service area.
    • If you do not choose dental at your initial enrollment you may not be able to obtain dental later on
  • If you choose to enroll in dental mark whether or not you have had 12 months of continuous dental coverage immediately preceding enrollment in PHIP dental coverage and provide the name of that dental coverage.


Section E

  • Select the payment option for how you will want to pay your monthly PHIP premiums.
    • If pension deduction is chosen, the pension holder will need to authorize by signing and dating this option
    • A voided check is needed if Electronic Funds Transfer (EFT) has been chosen


Section F

  • Answer all important questions on the 3rd page of the Enrollment Request Form


Section G

  • Read the Release of Information


Section H

  • Read the Lock-In statement


Section I

  • Read the I Agree to the Following information


Section J

  • You and your spouse, if enrolling, must sign and date the Enrollment Request Form
    • The date must be prior to the effective date noted on Page 1
    • If an individual is being added to coverage that is already established under PHIP (i.e. spouse is now Medicare eligible), only the enrolling party needs to sign the form. The pension holder will still need to sign under Payment Options if a change is being made to the premium under the pension deduction.
    • The effective date will be established by the receipt date, not the date signed


Section K

  • Fill out the Authorization to Disclose Protected Health Information if you would like someone to be able to contact PHIP on your behalf and obtain information.
    • This form is optional and can be filled out at a later date
    • The maximum duration that the Authorization is good for is 24 months and must be submitted again upon expiration of the previous document