Oregon Educators Benefit Board OEBB Documents, Forms and Guides

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Oregon Educators Benefit Board

Department

OEBB Documents, Forms and Guides

Educational Entity Forms

Educational Entity Guides

Educational Entity Reports

Member Forms

Member Guides

Member Instructions for Enrolling Online

Medicare Creditable and Noncreditable Coverage Notices

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Educational Entity Forms

For Education Entities: Click on the link to access the documents, to download, or to print. If you have questions, please call OEBB at 888-469-6322. Debit Agreement Form Electronic Funds Transfer Brochure MyOEBB Rules Selection Form MyOEBB Security Access and Access Termination Form MyOEBB Systems Training Registraton 2009 Payment Election Form SSN Consent Form


Educational Entity Guides

For Education Entities: Click on the link to access the MyOEBB Guides, download, or print. If you have questions, please call OEBB at 888-469-6322. Adding a Dependent Employment Change: Active to Retiree Imputed Values Mass Lock Out MyOEBB Educational Entity Administrator Guide MyOEBB New Hire Enrollment Guide QSC Detailed Matrix Guide Permanent File Format Process QSC Dates and 90-Day Credits Removing a Dependent Terminating an Employee by QSC with Benefits Enrollments


Educational Entity Reports

For Educational Entities: Click on the links to access reports for educational entities, to download, or to print. If you have questions, please call OEBB at 888-469-6322. 2008-09 Demographic Report

Member Forms

Appeal Form
Download the appeal form, complete, and return to OEBB. To submit an appeal by e-mail, write to OEBB.appeals@state.or.us.

Appeal Form

View the OEBB Complaint and Appeal Administrative policy.

Affidavit of Dependency and Domestic Partner; Termination of Domestic Partner
Download the affidavits or termination forms, complete, and return to your educational entity.

Affidavit of Dependency
Affidavit of Domestic Partnership
Termination of Domestic Partnership

Enrollment Forms
The enrollment form may be used to enroll in benefits and may be used instead of the online enrollment system. There is a separate form for the medical, dental and vision , and the optional benefits such as life and AD&D. Download the appropriate enrollment form, complete, and return to your educational entity.

Enrollment Form
Optional Enrollment Form Plan Year 2009

Group Life Conversion and Portability Forms
Use these forms for conversion or portability of group life.

Group Life Conversion Request Form
Group Life Portability Application

Reimbursement Forms
Click on the link to access the reimbursement forms, download, or print. If you have questions, please call OEBB at 888-469-6322.

Reimbursement Form -- Kaiser Permanente
Reimbursement Forms -- ODS medical, dental, vision and pharmacy
Reimbursement Form -- Providence

Transition of Care Forms
Click on the link to access the transition of care forms, download, or print. If you have questions, please call OEBB at 888-469-6322.

ODS Transition of Care
Providence Transition of Care


Member Guides

2009 Enrollment Brochure 2009 Member Guide MyOEBB New Hire Enrollment Guide Qualified Status Change Guide


Member Instructions for Enrolling Online

This link provides instructions for enrolling on benefits using the online enrollment system, MyOEBB. This brochure provides step-by-step instructions for enrolling online. You may download and distribute this brochure as needed. 2009 Enrollment Brochure

Medicare Creditable and Noncreditable Coverage Notices

These notices contain information about current prescription drug coverage with Oregon Educators Benefit Board and about individual's options under Medicare’s prescription drug coverage.

If you feel this information may apply to you, and you have questions, please call OEBB at (888) 469-6322.

Medicare Creditable Coverage Notice

Medicare Noncreditable Coverage Notice


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Page updated: November 09, 2009

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