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Forms - Health Care Facilitator

  • Retiree Forms

    • Medicare Factsheet
    • UBEN 100 (for retirees only)
    • UBEN 127PDF — Medicare Advantage Universal Enrollment/Election Form for Kaiser Senior Advantage
    • UBEN 125PDF — Medicare Advantage Universal Enrollment/Election Form for Health Net/Seniority Plus
    • UBEN 123PDF — Medicare Prescription Drug Plan Enrollment Form for UC Medicare PPO or UC High Option Supplement to Medicare
    • UBEN 101PDF — Medicare Advantage Prescription Drug Plan Disenrollment Form

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