Forms & Documents

Title
Form Number
Updated
Audience
Active Employee 2015 Reference Guide - 04/05/2015 EUTF/HSTA Active | HSTA VB Active
Active Employee 2016 Reference Guide - 04/19/2016 EUTF/HSTA Active | HSTA VB Active
Address Change Form for Retirees - 5/24/2016 EUTF Retiree | HSTA VB Retiree
Affidavit of “Dependency” for Tax Purposes - 12/30/2011 EUTF Retiree | EUTF/HSTA Active | HSTA VB Active | HSTA VB Retiree
Appeal Form - 8/4/2015 EUTF Retiree | EUTF/HSTA Active | HSTA VB Active | HSTA VB Retiree
Authorization for Release of Protected Health Information - 5/24/2016 EUTF Retiree | EUTF/HSTA Active | HSTA VB Active | HSTA VB Retiree
Authorized Leave of Absence without Pay L-1 10/23/2014 EUTF/HSTA Active | HSTA VB Active
Declaration of Domestic Partnership - - EUTF Retiree | EUTF/HSTA Active | HSTA VB Active | HSTA VB Retiree
Declaration of Termination of Civil Union - 12/30/2011 EUTF Retiree | EUTF/HSTA Active | HSTA VB Active | HSTA VB Retiree
Declaration of Termination of Domestic Partnership - - EUTF Retiree | EUTF/HSTA Active | HSTA VB Active | HSTA VB Retiree
Disability Certification for Dependent Children D-1 04/22/2016 EUTF Retiree | EUTF/HSTA Active | HSTA VB Active | HSTA VB Retiree
Enrollment Form for Active Employees 2016 EC-1 03/15/2016 EUTF/HSTA Active
Enrollment Form for HSTA VB Active BU 05/45 Employees 2016 EC-1H 03/15/2016 HSTA VB Active
Enrollment Form for HSTA VB Retirees EC-2H 08/25/2015 HSTA VB Retiree
Enrollment Form for Retirees EC-2 08/25/2015 EUTF Retiree
EUTF Retiree Worksheet – Effective 1/1/15 – 6/30-15 - 6/25/2015 EUTF Retiree
EUTF Retiree Worksheet – Effective 1/1/16 – 12/31/16 - 12/23/2015 EUTF Retiree
EUTF Retiree Worksheet – Effective 7/1/15 – 12/31/15 - 06/25/2015 EUTF Retiree
Example Medicare Card - 5/24/2016 EUTF Retiree | HSTA VB Retiree | Medicare Part B
Example Medicare Part B Reminder Notice for Member Letter - 05/25/2016 EUTF Retiree | HSTA VB Retiree | Medicare Part B
Example Medicare Part B Reminder Notice for Spouse/Partner Letter - 06/15/2016 EUTF Retiree | HSTA VB Retiree | Medicare Part B
Example Medicare Part B SSA verification letter - - EUTF Retiree | HSTA VB Retiree | Medicare Part B
Example Student Certification Letter - 05/25/2016 Cobra | EUTF/HSTA Active | HSTA VB Active
Examples of Student Verification Letters - 06/14/2016 EUTF Retiree | EUTF/HSTA Active | HSTA VB Active | HSTA VB Retiree
General Affidavit - 04/22/2016 EUTF Retiree | HSTA VB Retiree | Medicare Part B
HSTA VB Retiree Worksheet – Effective 1/1/15 – 12/31/15 - 10/20/2014 HSTA VB Retiree
HSTA VB Retiree Worksheet – Effective 1/1/16 – 12/31/16 - 12/23/2015 HSTA VB Retiree
Medicare Part B Reimbursement Direct Deposit Agreement Form - 5/24/2016 EUTF Retiree | HSTA VB Retiree | Medicare Part B
PCP Election Change Form (State of Hawaii Employees Only) – Link to DHRD Premium Conversion Plan Forms - 07/01/2008 EUTF/HSTA Active | HSTA VB Active
Retiree 2016 Reference Guide - 04/27/2016 EUTF Retiree | HSTA VB Retiree
State of Hawaii PCP – Domestic Partnership Acknowledgment Form (State of Hawaii Employees Only) Link to DHRD Premium Conversion Plan Forms PCP-DP - EUTF Retiree | EUTF/HSTA Active | HSTA VB Active | HSTA VB Retiree