WARNING: PROTECT YOUR PRIVATE HEALTH INFORMATION (PHI)! DO NOT email or fax completed forms.

NOTE: Original signature is required on forms and electronic submissions of forms will NOT be processed.

General Forms

Add/Remove Dependent(s) To/From Your Health Plans

You will need to complete a Health Benefits Change form if you wish to add/remove dependent(s) from your health plans. Supporting documentation will be required. A completed Health Benefits change form must be received by Health and Wellness within 30 days of a permitting event, unless otherwise noted in the Health Benefits Eligibility Policy.

• Health Benefits Change Form (PDF)

Change Address and Transition to Out of State Plans

You will need to complete an Address Change & Medical Plan Transition Request form if you move residences. If you move out of the enrollment areas and are currently enrolled in the Kern Legacy Classic Choice or Kern Legacy Max Choice Retiree Medical Plan, you will use this form to transition to the Out of State plan.

• Address Change & Medical Plan Transition Request (PDF)

Dis-enroll from County Health Benefits

You will need to complete a Retiree Request for Dis-enrollment form if you wish to cancel your health benefits coverage through the County.

• Retiree Request for Dis-Enrollment (for self or dependent) (PDF)

Kern Legacy Forms for Retirees Under Age 65

• Kern Legacy Share Select (PDF)
• Kern Legacy Network Plus (PDF)
• Kern Legacy Max Choice (PDF)
• Kern Legacy Classic Choice (PDF)

Medical Plan Benefits Forms for Retirees Over Age 65

Please call Health Benefits to receive the forms for our medical plan options offered to retirees over age 65.

Dental and Vision Forms

• Vision Service Plan (VSP) (PDF)
• Liberty Dental—CA40-R PLUS (PDF)