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Federal Health Benefits Election Form
Wednesday, August 1, 2012
Use this form to:
- Enroll or reenroll in the FEHB Program; or
- Elect not to enroll in the FEHB Program (employees only);or
- Change your FEHB enrollment; or
- Cancel your FEHB enrollment; or
- Suspend your FEHB enrollment (annuitants or former spouses only).
Complete, print, sign, and return pages 15 and 16 of the following form to the DCRB Benefits Department. at:
DCRB Benefits Department
900 7th St, 2nd Floor
Washington, DC 20001