Oregon Educators Benefit Board Forms

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Oregon Educators Benefit Board

Forms

OEBB Members

Enrollment and Change Forms
● New Hire Enrollment Form - revised 12/29/2011
● Midyear Change Form - revised 8/15/2011
● Open Enrollment Change Form - revised 8/19/2011
● Long Term Care Enrollment Form
● Are you eligible for OEBB benefits through HB 2557? Click Here.
Optional Insurance
● Beneficiary Designation Form
● Medical History Statement for life & disability insurance (online)
● Medical History Statement for long term care insurance (pdf)
● Terminate Long Term Care Insurance Form
● Click here for more forms and information on life & disability insurance
● Click here for more forms and information on long term care insurance
Covering Others
● Affidavit of Domestic Partnership
● Termination of Domestic Partnership Form
Appeal and Public Comment
● Appeal Form Review the OEBB Appeal Policy
● Public Comment Notice Form
Reimburse your unpaid claims (no guarantee of payment)
● Reimbursement Form - Kaiser Permanente
● Reimbursement Forms - ODS medical, dental, vision and pharmacy
● Reimbursement Form - Providence
Transition of Care
● Transition of Care Request Form - ODS
● Transition of Care Request Form - Providence
Weight Watchers
● Online subscription Proof of Participation Form Microsoft Word format (computer fillable form) Adobe pdf format (print blank form and complete manually)

If you have questions, please call OEBB at 888-469-6322

Need more help? Click Here.

Educational Entity

If you have questions, please call OEBB at 888-469-6322

Need more help? Click Here.

Can't find it?

Here's where you can find some other documents you may need:

Medicare Creditable and Noncreditable Coverage Notices

Please visit our "Required Notices" page.

Page updated: January 20, 2012