Medical and Dental Forms

Medical Enrollment and Change Form:

• Retiree Medical Enrollment and Change Form (HR-461)

Disability Certification for Overage Dependent Forms:

• Aetna (dental coverage) 
  (Both forms must be completed and submitted to Aetna):
  • Request for Continuation of Coverage For Disabled Child
  • Disabled Child Attending Physician’s Statement
• Cigna Open Access Plus (medical coverage)
  (Both forms must be completed and submitted to Cigna): 
  • Cigna Handicapped Disabled Dependent - Family Form
  • Cigna Handicapped Disabled Dependent - Physician Form
• Kaiser Permanente (medical coverage)
  • Contact Kaiser Member Services at 301-468-6000

Aetna Dental Benefits Request Form:

• Aetna Dental Benefits Request Form