Forms and Brochures

Each employing office must keep a supply of the following FEHB forms on hand to meet anticipated needs:

Forms for employee use:

• Health Benefits Election Form (SF 2809)
• Notice of Change in Health Benefits Enrollment (SF 2810)
• Temporary Continuation of Coverage (TCC) under the Federal Employees Health Benefits Program (RI 79-27)

Forms for employing office use:

• Report of Withholdings and Contributions for Health Benefits, Life Insurance, and Retirement (Lockbox) (SF 2812-L)
• Supplemental Semiannual Headcount Report (OPM Form 1523)

FEHB Brochures

Enrollee Brochures

Your FEHB carrier will make its brochure available to you before the beginning of each contract year.

Employing Office Brochures

Your employing office must keep a supply of FEHB Program carriers' plan brochures on hand for your reference.

You need to review the plan brochures so you will have enough information to make an informed choice.

On the Web

The OPM Healthcare website has helpful information about the FEHB Program. You can download plan brochures. The website also has links to carrier websites.

Distribution of the Reference Brochures: Before the annual Open Season begins, each fee-for-service plan distributes a supply of reference brochures to each agency's designated distribution point. This distribution point then ships the brochures to the installations it serves throughout the world.

Agency installations order HMO brochures directly from the HMOs, in a quantity determined in accordance with information provided by OPM. The plans then ship these brochures directly to the installation where they are available to you for reference.

Obtaining Forms

Employing offices obtain Standard Forms 2809 and 2810 directly from GSA supply centers, just as they do other OPM Standard Forms. Agencies do not need to maintain an internal procurement and distribution network for FEHB forms.

Agencies may reproduce Standard Form 2812-L and OPM Form 1523.

RI 79-27 is available to agencies by ordering from OPM riders issued at least annually.

Substitute Forms

Policy

The General Services Administration (GSA) allows the use of PC-based, agency-generated substitute forms, and OPM will accept substitute health benefits forms that meet GSA and OPM requirements.

General Requirements

Substitute forms must meet the general requirements established by GSA (41 CFR Part 201-9 and Bulletin B-3, 12g Electronic Generation of Standard and Optional Forms, as amended) and the requirements specified here. Substitute forms must be approved by OPM prior to their use.

The electronic reproduction must be complete, containing all instructions and questions that appear on the current official form. The wording and punctuation of all items, instructions, and identifying information must match exactly. No data element may be added to or deleted from the form. The sequence and format for each item on the form must be reproduced to the highest degree possible. Each item must print on the page in approximately the same location. The approval form must include the vendor/agency name and the OPM approval expiration date at the bottom of each page.

Form-Specific Requirements

Automated forms should be generated with black ink on white paper that is 8.5" wide and 11" long.

• Health Benefits Election form (SF 2809); no special requirements.
• Notice of Change in Health Benefits Enrollment (SF 2810); the instructions to Copy 1 (the Enrollee copy) must be on the reverse of Copy 1 or attached to it.

Copies

Agencies may photocopy standard forms that have carbon copies to create the needed copies when the original and the copy are identical. The original form must have an original signature. Copies may have a photocopy of the signature.

Approval Procedure

Agencies that develop substitute forms packages must submit a complete printed set of the forms and a fully functional copy of the program to OPM prior to actual use of the forms. OPM will issue approvals for one-year periods to ensure that the forms remain current.

Send requests for approval to Retirement and Insurance Service, Forms Analysis and Design, Room 4H28, 1900 E Street, NW, Washington, DC 20415.

Agencies that have developed, or plan to develop, automated forms that are populated from internal automated systems, and/or can store input to a data base, should contact OPM for information on direct data transmission via disk, tape, telephone or the Internet. Agencies may submit their plans to the address shown above, by email to cbenson@opm.gov, or call (202) 606-0623.

If a form is revised during the year, OPM will notify the substitute forms developer of the revision and the deadline for revision of the program.

Electronic Forms

Adobe Acrobat versions of most FEHB forms are available on OPM's website at OPM Forms.

Employee Express

Your employing office may allow you to make Open Season and other health benefits changes though "Employee Express" or another electronic method. Call your employing office for more information.

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