INSTRUCTIONS: ALABAMA HEALTH INSURANCE AND OPTIONAL STATUS CHANGE Alabama public education employees who are already enrolled in the state insurance program known as PEEHIP can use the form discussed in this article to make changes to their insurance coverage, as well as to certify or change their tobacco usage status. This document can be obtained from the website maintained by the Retirement Systems of Alabama. Alabama Health Insurance And Optional Status Change Step 1: Indicate with a check mark whether you are an active or retired member. Alabama Health Insurance And Optional Status Change Step 2: The first section requires information about the subscriber. Enter your Social Security or PID number, full name, date of birth and daytime phone number. Indicate your marital status with a check mark. Alabama Health Insurance And Optional Status Change Step 3: Indicate with check marks whether you or your spouse have used tobacco in the last 12 months. Alabama Health Insurance And Optional Status Change Step 4: If you have changed your name or employers, give your new name and/or date of employment transfer. Alabama Health Insurance And Optional Status Change Step 5: In the next section, indicate with check marks the changes you are requesting to be made. Alabama Health Insurance And Optional Status Change Step 6: Enter the date you are requesting that the changes take effect. Alabama Health Insurance And Optional Status Change Step 7: In the next section, indicate with check marks the reason for these requested changes. Alabama Health Insurance And Optional Status Change Step 8: The next section concerns documentation of dependents and is only to be completed if seeking family coverage. Alabama Health Insurance And Optional Status Change Step 9: The next section is only to be completed if you have the PEEHIP Supplemental Plan or other currently in effect group health, dental or vision coverage. Alabama Health Insurance And Optional Status Change Step 10: The next section must be completed if you or your dependents are eligible for Medicare. Alabama Health Insurance And Optional Status Change Step 11: The next section is only to be completed if you retired after September 30, 2005. Alabama Health Insurance And Optional Status Change Step 12: Sign and date the bottom of the page. Mail the completed document to the address at the top of the first page.