Form DPRS 2809 DPRS 2809 Request to Change FEHB or to Receive Plan Brochures for

Page 1

IMPORTANT
DIRECT PREMIUM REMITTANCE SYSTEM
DPRS OPEN SEASON INFORMATION
Please Note: You will receive this notification including direct links to OPM's open season materials along with the FEHB
SF-2809 form on page 2. Open Season information should be reviewed online to assist you in making your open season
changes.
Please visit the following web site for comprehensive information about your FEHB and Open Season at
www.opm.qov/healthcare-insurance/healthcare. You will find information on:
-

Open Season Resources
Comparing Plans
FEHB Handbook
Frequently Asked Questions
Medicare and FEHB
Health Care Reform/Affordable Care Act

If any additional assistance is needed in completing your form or questions regarding who is eligible to enroll in FEHB, periods
of eligibility, changing, or canceling enrollment, you may contact the National Finance Center, GISB Help Desk at
1-800-242-9630 from 8:00 a.m. to 4:00 p.m. CST, Monday thru Friday or you may also write to: USDA/NFC/DPRS Billing
Unit, P 0 Box 61760, New Orleans, LA, 70161-1760 or email to [email protected] or fax to 303-274-3805.
You may also visit our website at https://nfc.usda.gov/clientservices/insurance/services/dprs for important FEHB information.

Privacy Act Statement. The information you provide on this form is needed to document your enrollment in the Federal Employees Health Benefits
Program (FEHB) under Chapter 8, title 5, U.S. Code. This information will be shared with the health insurance carrier you select so that it may (1)
identify your enrollment in the plan (2) verify your and/or your family's eligibility for payment of a claim for health benefits services or supplies, and
(3) coordinate payment of claims with other carriers with whom you might also make a claim for payment of benefits. This information may be
disclosed to other Federal agencies or Congressional offices which may have a need to know it in connection with your application for a job, license,
grant, or other benefit. It may also be shared and is subject to verification, via paper, electronic media, or through the use of computer matching
programs, with national, state, local, or other charitable or social security administrative agencies to determine and issue benefits under their programs
or to obtain information necessary for determination or continuation of benefits under this program, In addition, to the extent this information
indicates a possible violation of civil or criminal law, it may be shared and verified, as noted above, with an appropriate Federal, state, or local law
enforcement agency.
While the law does not require you to supply all the information requested on this form, doing so will assist in the prompt processing of your
enrollment.
We request that you provide your Social Security Number so that it may be used as your individual identifier in the FEHB program. Executive Order
9397 (November 22, 1943) allows Federal agencies to use the Social Security Number as an individual identifier to distinguish between people with the
same or similar names. Failure to furnish the requested information may result in the U.S. Office of Personnel Management's (OPM) inability to ensure
the prompt payment of your and/or your family's claims for health benefits services or supplies.
Agencies other than the OPM may have further routine uses for disclosure of information for the records system in which the file copies of this form.
If this is the case, they should provide you with any such uses which are applicable at the time they ask you to complete this form.
Public Burden Statement. We estimate, this form takes an average of 45 minutes to complete, including the time for reviewing instructions, getting
the needed data, and reviewing the completed form. Send comments regarding our time estimate or any other aspect of this form, including suggestions
for reducing completion time, to the National Finance Center, Direct Premium Unit (DPRS) Billing Unit, P.O. Box 61760, New Orleans, LA 70161,
10500-00241. The OMB number, 0500-0024 is currently valid. NFC may not collect this information, and you are not required to respond, unless this
number is displayed.

0R574 (revised 10/171

FEDERAL EMPLOYEES
HEALTH BENEFITS
PROGRAM

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Read the enclosed instructions before completing this form. Return this form to:
USDA/NFC, DPRS Billing Unit, P.O. Box 61760, New Orleans, LA 70161
You may fax your form to 303-274-3805.
Do not take any action to maintain your present coverage.

FEHB

OPEN SEASON
DPRS-2809
OMB 0505-0024
(Revised 10115)

COMPLETE THIS FORM ONLY IF YOU ARE MAKING CHANGES.
All plan brochure requests must be made through the carrier from whom you wish to receive the brochure
or from the FEHB web site at www.opm.gov/insure/health.

SECTION I - Enrollee and Family Member Information (For additional family members use a separate sheet and attach.)
1. ENROLLEE NAME (last, first, middle initial)

3. DATE OF BIRTH (mm/dcl/Wyy)

2 SOCIAL SECURITY NUMBER

5. ARE YOU MARRIED?

m nF
I need to correct my address.
The changes are indicated h tern 6

6. HOME MAILING ADDRESS (including ZIP Code)

11
10. INDICATE THE TYPE(S) OF OTHER INSURANCE

n

TRICARE

n OTHER

nFEHB

YES

7.1F YOU ARE COVERED BY MEDICARE, CHECK ALL THAT APPLY

[]NO

U. MEDICARE CLAIM NUMBER

-1 D

A

9. ARE YOU COVERED BY INSURANCE OTHER THAN MEDICARE?

An FEHB self and family enrollment covers all eligible family members. No
person may be covered under more than one FEHB enrollment.

YES, indicate in tern 10 below.
NAME OF OTHER INSURANCE

1N0
POLICY NUMBER

Dependents' Information. Fill in the applicable information in the blocks below. For additional family membe s please use a separate sheet of paper. Relationship Codes are: 01. Spouse;
19. Child under age 26; 09. Adopted child; 17. Step child; 10. Eligible foster child; 99. Disabled child age 26 or older who is incapable of self-support because of a physical or mental
disability that began before his/her 26th birthday.
11. NAME OF FAMILY MEMBER (last, first, middle initial)

13. DATE OF BIRTH (mmiddlyyyy)

12. SOCIAL SECURITY NUMBER

14. SEX

15. RELATIONSHIP CODE

F

-1. n
17.1F YOU ARE COVERED BY MEDICARE, CHECK ALL THAT APPLY 18. MEDICARE CLAIM NUMBER

16. ADDRESS (if different from enrollee)

A

-I B

n0

19. ARE YOU COVERED BY INSURANCE OTHER THAN MEDICARE?

20.INDICATE THE TYPE(S) OF OTHER INSURANCE

nTRICARE n OTHER n FEHB

An FEHB self and family enrollment covers all eligible family members. No
person may be covered under more than one FEHB enrollment.

21.EMAIL ADDRESS (if home address is different from enrollee's)

-1 YES, indicate in tem 20 below.
NAME OF OTHER INSURANCE

-I NO
POLICY NUMBER

22.PREFERRED TELEPHONE NUMBER (if home address is different from enrollee's)

24.SOCIAL SECURITY NUMBER

23.NAME OF FAMILY MEMBER (last, first, middle initial)

25.DATE OF BIRTH (mmIddftyy)

26.SEX

27.RELATIONSHIP CODE

n

-I.
F
29.1F YOU ARE COVERED BY MEDICARE, CHECK ALL THAT APPLY 30. MEDICARE CLAIM NUMBER

28.ADDRESS (if different from enrollee)

7A

7B

nD

31. ARE YOU COVERED BY INSURANCE OTHER THAN MEDICARE?

7

32.INDICATE THE TYPE(S) OF OTHER INSURANCE

[1

TRICARE

n OTHER n FEHB

An FEHB self and familyenrollment covers all eligible family members. No
person may be covered under more than one FEHB enrollment.

33.EMAIL ADDRESS (if home address is different from enrollee's)

-I NO
POLICY NUMBER

34.PREFERRED TELEPHONE NUMBER (if home address is different from enrollee's)

SECTION ll - FEHB Plan You Are Currently Enrolled In
1. PLAN NAME

YES, indicate h tern 32 below.
NAME OF OTHER INSURANCE

Section III - FEHB Plan You Are Changing to
2. ENROLLMENT CODE

I. PLAN NAME

2. ENROLLMENT CODE

SECTION IV - Signature
WARNING: Any intentionally false statement in this application or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than $10,000 or
imprisonment of not more than 5 years, or both. (18 U.S. C. 1001.)
I. YOUR SIGNATURE (do not print)

2. DATE (mmIddlyyyy)

3 EMAIL ADDRESS

4. PREFERRED TELEPHONE NUMBER
(

0R25A (revised 10/15)