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Enrollment/Change/Cancellation Forms
To initiate an enrollment, change, or cancellation of your dental/vision plan, fill out the appropriate form below.
To help you complete your healthcare forms accurately, we have created detailed, step-by-step instructions and samples to use as a reference while filling out your forms. Please click on the appropriate sample below.
- Medical Plan Enrollment, Change, Cancellation Form (Form NC)
- Dental and Vision Plan Enrollment, Change, Cancellation Form (Form DCD)
- Medicare Advantage Prescription Drug Plan Enrollment Form
Brochures & Rate Tables
- Medical & Dental/Vision Premium Rates
- Medical Premium Rates - Out of Area
- Dental Vision Chart
- Plan Comparison
- Plan Comparison - Medicare
- Plan Comparison - Out of Area
- Medicare Benefits Chart
- How Your Anthem Blue Cross Plans I, II, and III Coordinate with Medicare
- Changing Medical Plans
New Retiree Healthcare Packet
- Exploring Your Healthcare Benefits Through LACERA
- Contact Information
- Decision Guide
- Dental/Vision Plans
- Medical Plans Overview
- When You Travel
- Request Enrollment Forms
Annual Retiree Healthcare Packet
To order healthcare forms and packets, call Retiree Healthcare Division at 800-786-6464.
To order other retirement information, visit the Forms and Publications page.