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Benefit Forms

Santa Barbara County Employee Medical Plans
•	Aetna
	HMO Low Option Enrollment Form
	HMO High Option Enrollment Form
	POS Point-of-Service Enroll Form
	Open Access Plan (PPO) Enroll Form
	HDHP High Deductible PPO Enroll Form
	Mail Order - Aetna Rx Home Delivery -- Order Form
	Medical Claim Form
•	Kaiser Permanente (Ventura County only)
	HMO Low or High Option Enroll Form - indicate which plan you are enrolling in.
	Zip Code Listing of Eligible Enrollment Areas
Santa Barbara County Employee Dental Plans
•	County Self-Funded Dental Plan
		Enrollment Form
		Change of Status Form
		Claim Form
		Pre-Authorization: Attending Dentist's Statement
•	Golden West Pacesetter HMO Plan
		Enrollment Form
		Change of Status Form
VSP Vision Plan
		VSP Benefits
		VSP Enroll Form
		VSP Provider Finders
		VSP Claim Form (for non-VSP providers)
Insurance Waiver
		Waiver of Medical/Dental Coverage
Combined Coverage
		Combined Coverage Request Form
Status Change
		Status Change Form
Commuter Benefits
		Lost Pass Form