ENROLLMENT AND CLAIM FORMS - DEPENDENT CHILDREN HEALTH BENEFIT PLAN
Click on the appropriate link below to download a printable PDF file of the selected form.

The forms below function as either Screen Viewable forms, indicated by the symbol:
or Screen Fillable forms, which are labeled with the button:
(Screen Fillable forms require you use Adobe Acrobat 5.0, or higher.)

Dependent Children Health Benefit Plan (DHBP) forms:
NOTE:  Employees of FBI, USSS, DEA, ATF, CBP, CIS, and ICE must complete the SAMBA Payroll Allotment Form 299.  All other agencies must complete the Direct Debit application.
Form Description PDF Type Premium

ENROLLMENT FORMS
DHBP Enrollment Form
DHBP Dental Enrollment
Allotment Form 299
Direct Debit Application Form

HEALTH PLAN CLAIM FORMS
Health Claim Form
SAMBA Dental Claim Form

SUPPLEMENTAL DENTAL/VISION PLAN FORMS
Aetna Alternate Dental Claim Form
Vision Claim Form



Get Acrobat Reader
Click on the link above if you need to download a free copy of the program.