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Benefit Forms

 

Santa Barbara County Employee Medical Plans
•	Blue Shield HMO
		Enrollment Form
		Membership Change Form
		Member Claim Form
		Prescription by Mail Program and Order Form Phone: 866-346-7200
		Request for Continuity Care of Service
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
Status Change
		Status Change Form
Commuter Benefits
		Lost Pass Form