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Pa enrollment change form

Pa enrollment change form 2026

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The document outlines the enrollment process for health coverage under the Pennsylvania State System of Higher Education (PASSHE). It includes sections for employees to add or remove dependents, select health plan options, and provide personal and dependent information. The document also details eligibility criteria for dependents, circumstances under which changes can be made outside of open enrollment, and the necessary actions required by employees to manage their health benefits.

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Click ‘Get Form’ to open the PA Enrollment Change Form in the editor.
Begin by filling out the 'Employee Demographic Information' section. Enter your name, address, and Social Security number accurately.
Select your health plan choices from the options provided, such as PPO or HMO. If you wish to waive medical benefits, indicate that clearly.
In the 'Dependent Data' section, add or remove dependents as necessary. Ensure you provide their names, dates of birth, and Social Security numbers.
Complete the 'Other Coverage Data' section by answering questions about any additional health coverage for you or your dependents.
Finally, review all entries for accuracy before signing and dating the form at the bottom. This ensures your application is processed smoothly.

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