To submit the completed form, mail it to the address provided on the form: 4002 Loop 322, Abilene, TX 79602-7330. Alternatively, you may also fax it to (800) 252-8039. Ensure that your submission is completed accurately to avoid any processing delays and follow any specific submission instructions as dictated by your health plan.

Important dates for this form include the new employee enrollment period starting from January 1 every year and the Summer Enrollment period typically occurring in July. Ensure submissions are completed in advance to avoid gaps in coverage. Check specific deadlines with your health plan for any updates.

The purpose of this form is to facilitate the enrollment process for health benefits under the Texas Employees Group Benefits Program. It ensures that all necessary employee and dependent information is accurately collected to provide essential health coverage. Additionally, the form serves as a means to update any existing health plan information as required.

• 1. Employee Data: Collects personal information including name, mailing address, and contact numbers.
• 2. Other Insurance Data: Requests information about any additional health coverage the employee or their family may have.
• 3. Medicare Coverage Information: Information related to Medicare Part A and Part B coverage.
• 4. Primary Care Provider Selection: Details to select a primary care provider from a specified health plan.
• 5. Other Covered Dependent: Information about dependents who are not living in the household.

Failure to submit this form may result in delays in receiving health benefits or identification cards. Incomplete submissions can lead to complications during the enrollment process.

• Delayed Coverage: Your health benefits may not become active in a timely manner, leading to potential gaps in coverage.
• Inaccurate Information: Incomplete or incorrect information may cause issues in processing your benefits or claims.
• Non-compliance with Health Plan Requirements: Failure to submit the required information may result in non-compliance with your health plan's policies.

• 1. New Enrollment: To enroll in any of the Texas Employees Group Benefits programs.
• 2. Adding Dependents: When there is a need to include family members in your health plan.
• 3. Updating Personal Information: To maintain current and correct information in your health records.
• 4. Making Coverage Changes: During annual enrollment periods or changes due to life events.
• 5. Medicare Updates: For updating information related to Medicare coverage.