Forms

• Benefits Enrollment Form, 1751a (pdf)
• Casual Employee Benefits Enrollment Form (pdf)
• Declaration of Domestic Partnership, 1925a (pdf)
• Declaration of Legal Ward as Eligible Dependent, 3028 (pdf)
• Declaration that Enrolled Dependent Meets IRS Requirements for Tax-Favored Health Premium Contributions, 3027 (pdf)
• Universal Beneficiary Designation Change Form, 1938 (pdf)

Required notices

• Required Notices Package (pdf)
  Package includes:
  • Continuation Coverage Rights Under COBRA
  • Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
  • Notice from LANS about Your Prescription Drug Coverage and Medicare
  • Women’s Health and Cancer Rights Act (WHCRA)
  • Wellness Reward Alternative
  • HIPAA Special Enrollment Rights
  • Health Insurance Marketplace Coverage Options
• LANL HIPAA Privacy Notice (pdf)
• New Health Insurance Marketplace Coverage Notice (pdf)
• Required Annual Notices by Law for Active Employees (pdf)
• Required Annual Notices by Law for Retirees (pdf)