Appendix II, Instructions on Completing the SF 2809

This topic has been updated to replace the field name Medicare Claims Number with the new Medicare Beneficiary Identifier.

SF 2809, Health Benefits Election Form
Part A - Enrollee and Family Member's Information

Field	Description
Enrollee name	Enter last, first, and middle initial.
Social Security Number	Enter Social Security number (SSN). Separated employee, child, or ex-spouse's SSN.
Date of birth	Enter Date of Birth (mm/dd/yyyy). Separated employee, child, or ex-spouse's date of birth (Month, Day, and Year).
Sex	Check the appropriate block (M - Male or F - Female).
Are you married?	Check the appropriate block (Y - Yes or N - No). Note: If you are separated but not divorced, you are still married.
Home mailing address	Enter enrollee's mailing address. Number, street or rural route, city, State, and ZIP Code of the separated employee, child, or ex-spouse's mailing address.
If you are coved by Medicare	Check all that apply (A, B, or D).
Medicare Beneficiary Identifier	Enter Medicare Beneficiary Identifier. Note: This number is on your Medicare card.
Are you covered by insurance other than Medicare?	Check the appropriate block. (Yes or No. If yes, specify in item 34 below.)
Indicate the type(s) of other insurance:	Check all that apply (TRICARE, FEHB, or Other). FEHB - An FEHB self and family enrollment covers all eligible family members. No person may be covered under more then one FEHB enrollment. Other - Enter the name of other insurance and policy number.
Email address	Enter enrollee's email address.
Preferred telephone number	Enter the enrollee's preferred telephone number.
Name of family member	List all eligible family members (last, first, and middle initial). Spouse must be listed first.
Social Security number	Enter the dependent's SSN.
Date of birth	Enter the dependent's date of birth (mm/dd/yyyy).
Sex	Check the appropriate block (M = Male or F = Female).
Relationship code	Enter the appropriate code as follows: Relationship code 01 = Spouse 19 = Child under age 26 09 = Adopted Child 17 = Stepchild 10 = 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.
Address	Enter the street or rural route, city, State, and ZIP Code of the separated employee, child, or ex-spouse's mailing address (number and street).
If this family member is covered by Medicare	Check all that apply. Note: Including prescription drug coverage under Medicare Part D.
Medicare Beneficiary Identifier	Enter the Medicare Beneficiary Identifier. Note: This number is on your Medicare card.
Is this family member covered by insurance other than Medicare?	Check the appropriate block. (Yes or No. If yes, specify in item 34 below.)
Indicate the type(s) of other insurance	Check all that apply (TRICARE, FEHB, or Other). FEHB - An FEHB self and family enrollment covers all eligible family members. No person may be covered under more than one FEHB enrollment. Other - Enter the name of other insurance and policy number.
Email address	Enter the dependent's or enrollee's email address.
Preferred telephone number	Enter the dependent's or enrollee's preferred telephone number.
Name of family member	List all eligible family members (last, first, and middle initial). Spouse must be listed first.
Social Security number	Enter the dependent's SSN.
Date of birth	Enter the dependent's date of birth (mm/dd/yyyy).
Sex	Check the appropriate block (M = Male or F = Female).
Relationship code	Enter the appropriate code as follows: Relationship code 01 = Spouse 19 = Child under age 26 09 = Adopted Child 17 = Stepchild 10 = 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.
Address	Enter the street or rural route, city, State, and ZIP Code of the separated employee, child, or ex-spouse's mailing address (number and street).
If this family member is covered by Medicare	Check all that apply. Note: Including prescription drug coverage under Medicare Part D.
Medicare Beneficiary Identifier	Enter the Medicare Beneficiary Identifier. Note: This number is on your Medicare card.
Is this family member covered by insurance other than Medicare?	Check the appropriate block. (Yes or No. If yes, specify in item 34 below.)
Indicate the type(s) of other insurance	Check all that apply (TRICARE, FEHB, or Other). FEHB - An FEHB self and family enrollment covers all eligible family members. No person may be covered under more then one FEHB enrollment. Other - Enter the name of other insurance and policy number.
Email address	Enter the dependent's or enrollee's email address.
Preferred telephone number	Enter the dependent's or enrollee's preferred telephone number.
Name of family member	List all eligible family members (last, first, and middle initial). Spouse must be listed first.
Social Security number	Enter the dependent's SSN.
Date of birth	Enter the dependent's date of birth (mm/dd/yyyy).
Sex	Check the appropriate block (M = Male or F = Female).
Relationship code	Enter the appropriate code as follows: Relationship code 01= Spouse 19 = Child under age 26 09 = Adopted Child 17 = Stepchild 10 = 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.
Address	Enter the street or rural route, city, State, and ZIP Code of the separated employee, child, or ex-spouse's mailing address (number and street).
If this family member is covered by Medicare	Check all that apply. Note: Including prescription drug coverage under Medicare Part D.
Medicare Beneficiary Identifier	Enter the Medicare Beneficiary Identifier. Note: This number is on your Medicare card.
Is this family member covered by insurance other than Medicare?	Check the appropriate block. (Yes or No. If yes, specify in item 34 below.)
Indicate the type(s) of other insurance	Check all that apply (TRICARE, FEHB, or Other). FEHB - An FEHB self and family enrollment covers all eligible family members. No person may be covered under more then one FEHB enrollment. Other - Enter the name of other insurance and policy number.
Email address	Enter the dependent's or enrollee's email address.
Preferred telephone number	Enter the dependent's or enrollee's preferred telephone number.

Enter the enrollee name and date of birth at the top of the page.

Part B - FEHB Plan You Are Currently Enrolled In (If Applicable)

Field	Description
Plan name	Enter the plan name.
Enrollment code	Enter the enrollment code.

Part C - FEHB Plan You Are Enrolling In or Changing To

Field	Description
Plan name	Enter the elected health benefits plan name.
Enrollment code	Enter the elected health benefits plan three-digit enrollment code.

Part D - Event That Permits You to Enroll, Change, or Cancel

Field	Description
Event code	Enter the event code.
Date of event	Enter the date of event.

Part E - Election NOT to Enroll (Employees Only)

I do NOT want to enroll in the FEHB Program.
Place an "X" in the box if the enrollee wishes not to enroll in the FEHB Program.

Note: Signature in Part H certifies that they have read and understand the information on page 3 regarding this election.

Part F - Cancellation of FEHB

I CANCEL my enrollment.
Place an "X" in the box if the enrollee wishes to cancel FEHB enrollment.

Note: Signature in Part H certifies that they have read and understand the information on page 3 regarding cancellation of enrollment.

Part G - Suspension of FEHB (Annuitants/Former Spouses Only)

I SUSPEND my enrollment.
Place an "X" in the box if your are an annuitant or former spouse wishing to suspend your FEHB enrollment.

Note: Signature in Part H certifies that they have read and understand the information on page 4 regarding suspension of enrollment.

Part H - Signature

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.)

Field	Description
Your signature	Sign the SF 2809 form (do not print).
Date	Enter the date the form was signed (mm/dd/yyyy).

Part I - To Be Completed by Agency or Retirement System

Enter the appropriate remarks. Also, please enter the name and telephone number of the person completing this form in the Remarks block. Example: Form Completed by: Jane Doe, Telephone No. (123) 456-7890.

Field	Description
Date received	Enter the date received (mm/dd/yyyy).
Effective date of action	Enter the effective date of action (mm/dd/yyyy).
Personnel telephone number	Enter the Personnel telephone number.
Name and address of Agency or retirement system	Enter the name and address of Agency or retirement system.
Authorizing official	Enter the name of the Authorizing official (please print).
Signature of authorized agency official	Enter Signature of authorized Agency official.
Payroll office number	Enter the Payroll office number.
Payroll office contact	Enter the Payroll office contact (please print).
Payroll telephone number	Enter the Payroll telephone number.

Direct Premium Remittance System (DPRS)