• HEALTH BENEFIT PLAN ENROLLMENT FORM (PERS-HBD-12)

    PRIVACY INFORMATION - FUSD USES FORMSITE FOR DATA COLLECTION (Security INFO)

    Submission of the requested information is mandatory. The information requested is collected pursuant to the California Government Code (sections 20000 et seq.) and will be used for administration of the Board’s duties under the Retirement Law, the Social Security Act, and the Public Employees’ Medical and Hospital Care Act, as the case may be. Portions of this information may be transferred to another governmental agency (such as your employer) but only in strict accordance with current statutes regarding confidentiality. Failure to supply the information may result in the System being unable to perform its functions regarding your status.

    You have the right to review your membership files maintained by the System. For questions concerning your rights under the Information Practices Act of 1977, please contact the Information Practices Act Coordinator, CalPERS, P.O. Box 942702, Sacramento, CA 94229- 2702.

    Section 7(b) of the Privacy Act of 1974 (Public Law 93-579) requires that any federal, state, or local governmental agency which requests an individual to disclose his Social Security account number shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it. Section 111 of Public Law 101-173 requires group health plans to collect and provide member Social Security numbers for the coordination of federal and state benefits. Furthermore, Health Account Services requires each enrollee’s Social Security number for identification purposes and to verify eligibility for benefits. Specifically, the California Public Employees’ Retirement System uses Social Security numbers for the following purposes:

    1. Enrollee identification for eligibility processing and eligibility verification.

    2. Payroll deduction and state contribution for state employees.

    3. Billing of contracting agencies for employee and employer contributions.

    4. Reports to the Public Employees’ Retirement System and other state agencies.

    5. Coordination of benefits among carriers.


    BINDING ARBITRATION

    Enrollment in certain plans constitutes an agreement to have any issue of medical malpractice decided by neutral arbitration and waiver of any right to a jury or court trial. Refer to the health plan Evidence of Coverage booklet to determine if this provision is applicable to your plan.


    Privacy Notice

    The privacy of personal information is of the utmost importance to CalPERS. The following information is provided to you in compliance with the Information Practices Act of 1977 and the Federal Privacy Act of 1974.

    Information Purpose

    The information requested is collected pursuant to the Government Code (sections 20000 et seq.) and will be used for administration of Board duties under the Retirement Law, the Social Security Act, and the Public Employees’ Medical and Hospital Care Act, as the case may be. Submission of the requested information is mandatory. Failure to comply may result in CalPERS being unable to perform its functions regarding your status.

    Please do not include information that is not requested.

    Social Security Numbers

    Social Security numbers are collected on a mandatory and voluntary basis. If this is CalPERS’ first request for disclosure of your Social Security number, then disclosure is mandatory. If your Social Security number has already been provided, disclosure is voluntary. Due to the use of Social Security numbers by other agencies for identification purposes, we may be unable to verify eligibility for benefits without the number.

    Social Security numbers are used for the following purposes:

    1. Enrollee identification

    2. Payroll deduction/state contributions

    3. Billing of contracting agencies for employee/ employer contributions

    4. Reports to CalPERS and other state agencies

    5. Coordination of benefits among carriers

    6. Resolving member appeals, complaints, or grievances with health plan carriers

    Information Disclosure

    Portions of this information may be transferred to other state agencies (such as your employer), physicians, and insurance carriers, but only in strict accordance with current statutes regarding confidentiality.

    Your Rights You have the right to review your membership files maintained by the System. For questions about this notice, our Privacy Policy, or your rights, please write to the CalPERS Privacy Officer at 400 Q Street, Sacramento, CA 95811 or call us at 888 CalPERS (or 888-225-7377).