INSTRUCTIONS: ALABAMA PEEHIP HEALTH INSURANCE AND OPTIONAL STATUS CHANGE

Alabama public employees enrolled in the state-administered health insurance plan use the document discussed in this article to make an optional status change. This document can be obtained from the website maintained by the Retirement Systems of Alabama.

Alabama PEEHIP Health Insurance And Optional Status Change Step 1: Indicate whether you are an active or retired member with a check mark.

Alabama PEEHIP Health Insurance And Optional Status Change Step 2: The first section concerns the subscriber. On the first line, enter your Social Security number or PiD number, first name, middle name or initial and last name.

Alabama PEEHIP Health Insurance And Optional Status Change Step 3: On the second line, enter your date of birth and daytime phone number, as well as indicating your marital status with a check mark.

Alabama PEEHIP Health Insurance And Optional Status Change Step 4: On the third line, indicate with a check mark whether you or your spouse have used tobacco products in the last 12 months.

Alabama PEEHIP Health Insurance And Optional Status Change Step 5: In the next two blank boxes, if you have changed names, enter your previous full name and new full name.

Alabama PEEHIP Health Insurance And Optional Status Change Step 6: In the next blank box, if you have changed jobs, enter your date of employment transfer.

Alabama PEEHIP Health Insurance And Optional Status Change Step 7: In the next section, indicate the type of coverage change you wish to make by placing a check mark next to the applicable statement. Enter your requested effective date at the bottom of this section.

Alabama PEEHIP Health Insurance And Optional Status Change Step 8: In the next section, indicate the reasons for these changes by checking all applicable statements.

Alabama PEEHIP Health Insurance And Optional Status Change Step 9: The next section concerns dependents and is only required for family coverage.

Alabama PEEHIP Health Insurance And Optional Status Change Step 10: The next section at the top of the second page must be completed if the member elects the PEEHIP supplemental plan or if the member or their dependents have other group health, dental or vision coverage currently in effect.

Alabama PEEHIP Health Insurance And Optional Status Change Step 11: Provide all other information requested. Sign and date the bottom of the form.