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80% Authorization Form ACRE Enrollment Form Active or Deferred Member Beneficiary Designation Form Address and Name Change Form (Retirees, Payees, and Deferred Members) Affidavit of Dependent Eligibility Affidavit of Domestic Partnership Agreement and Order for Division of Retirement Benefits – Separate Records Agreement and Order for Division of Retirement Benefits – Shared Records Application For Disability Retirement (Sample Only) Application for Service Retirement Aquilino Tier 1 Restoration Application Authorization for Release of Information and Documents Community Property Estimate Request Form Confidentiality Policy Data Correction Form (Active and Deferred Members) Declaration of Qualification for Registration as Domestic Partners Dental Enrollment Form Direct Deposit Form HIPAA Authorization Form HIPAA Cancellation Form IRS Form W-9 Kaiser Permanente Senior Advantage (KPSA) Enrollment Form Medical Enrollment Form Medicare Part B Reimbursement Plan (MBRP) Application Form Member Enrollment Questionnaire Multiple Continuance Beneficiary Addendum Non-Member Application for Retirement Allowance Non-Member Beneficiary Form Notice of Claim Other Public Service Verification Form Power of Attorney Purchase Request Form REAC Enrollment Form Report a Death Form Request for Joinder Packet Retired Member Beneficiary Designation Form Retirement Estimate Request Form SSA-44 Form (Medicare Income-Related Monthly Adjustment Form) Survivor Continuance Recipient's Designation of Beneficiaries Form Tax Withholding Designation Form (IRS Federal Form W-4P) Tax Withholding Designation Form (State of California) Termination Election of Membership Request Form Termination of Domestic Partnership Verification of Enrollment Status Via Benefits Reimbursement Forms at viabenefits.com Vision Plan Enrollment Form VSP Reimbursement Form
