Std 692 form 2026

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The document is a Dental Plan Enrollment Authorization form from the California Department of Human Resources. It outlines the process for employees to enroll in, cancel, or change their dental plan coverage, including sections for personal information, dependent details, and authorization for payroll deductions. It also includes a privacy notice regarding the handling of personal information.

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Click ‘Get Form’ to open the std 692 form in the editor.
Begin with Section A by entering your name and selecting the dental plan you wish to enroll in. If applicable, provide the provider/facility number for prepaid plans.
In Section B, indicate the type of action: whether you are enrolling for the first time, canceling, or changing plans. Fill out all relevant fields based on your choice.
If changing family member enrollment, list all current members and specify any additions or deletions along with their action codes in Section B.
Complete Section C if applicable, providing details about your prior dental plan if you are making changes.
In Section D, check the appropriate box regarding your enrollment decision and provide your signature and date signed at the bottom of this section.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (124 Votes)
2019	4.4 Satisfied (251 Votes)
2016	4.3 Satisfied (129 Votes)
2012	4.4 Satisfied (180 Votes)
2000	4 Satisfied (44 Votes)

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