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 Benefits

VSP Enroll Form

VSP Provider Finders

VSP Claim Form(for non-VSP providers)

Insurance Waiver

Waiver of Medical/Dental Coverage

Status Change

Status Change Form

Commuter Benefits 

Lost Pass Form