To download (or print) a PDF of a document shown on this page, click on the link under the item. NOTE: If you are having difficulty accessing a PDF, you may need to upgrade to the most recent version of Adobe Reader; it's free.
Enrollment/Change/Cancellation Forms:
To initiate an enrollment, change, or cancellation of your dental/vision or medical plan, fill out the appropriate form below.
Sample forms: To help you complete your healthcare forms accurately, we have created detailed, step-by-step instructions and samples to use as a reference while filling out your forms. Please click on the appropriate sample below.
- Dental and Vision Plan - New Enrollment, Change, Cancellation (Form DCD)
- Medical Plan New Enrollment, Change, Cancellation (Form NC)
- Medicare Advantage Prescription Drug Plan Enrollment Form
Brochures & Rate Tables
- Medical & Dental/Vision Premium Rates
- Medical Premium Rates - Out of Area
- Dental Vision Chart
- Plan Comparison
- Plan Comparison - Medicare
- Plan Comparison - Out of Area
- Medicare Benefits Chart
- How Your Anthem Blue Cross Plans I, II, and III Coordinate with Medicare
- Changing Medical Plans
New Retiree Healthcare Packet
- Exploring Your Healthcare Benefits Through LACERA
- Contact Information
- Decision Guide
- Dental/Vision Plans
- Medical Plans Overview
- When You Travel
- Request Enrollment Forms
Annual Retiree Healthcare Packet
To order healthcare forms and packets, call 800-786-6464, and press 1 for Retiree Healthcare.
To order other retirement information, visit the Forms and Publications page.