Energy hcfederal-employee-healthFederal Employee Health Benefits (FEHB)Department of Energy 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the designated field, ensuring you include your last name, first name, and middle initial.
3. Input today's date in the format mm-dd-yyyy to document when you are filling out this form.
4. Provide your Social Security Number and Date of Birth in the respective fields, formatted as mm-dd-yyyy.
5. Fill in your Enrollment Code as indicated on your Earnings and Leave Statement.
6. Specify the Effective Date of Nonpay Status using the mm-dd-yyyy format.
7. Select whether you elect to terminate or continue your health benefits enrollment by checking the appropriate box.
8. If continuing coverage, indicate how you will pay premiums—directly or by incurring a debt—and provide any necessary details.
9. Complete your contact information including address, city/state/ZIP, telephone number, and email address for communication purposes.
10. Sign and date the form at the bottom to acknowledge that you understand the conditions outlined above before submitting it through our platform.

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