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OEBB Documents, Forms and Guides
Appeals
Affidavits
Benefit Plan Selection Form for Educational Entities
Enrollment Form
Medicare Creditable and Noncreditable Coverage Notices
MyOEBB Forms
MyOEBB Guides
Premium Collection Forms and Documents
Reimbursement Forms
Transition of Care Forms
Appeals
 
Download the appeal form, complete, and return to OEBB.
 
If you have questions, please call OEBB at (888) 469-6322.
 
To submit an appeal by e-mail, write to OEBB.appeals@state.or.us.
 
 
Appeal Form 
 
 
View the OEBB Complaint and Appeal Administrative policy.
 

Affidavits
 
Download the affidavits, complete, and return to your district.
 
If you have questions, please call OEBB at (888) 469-6322.
 
Affidavit of Dependency
 
Affidavit of Domestic Partnership

Benefit Plan Selection Form for Educational Entities
 
For Educational Entities: Download the benefit plan selection form, complete, and return to OEBB.
 
If you have questions, please call OEBB at (888) 469-6322.
 
 
Benefit Plan Selection Form

Enrollment Form
 
Download the enrollment form, complete, and return to your district. This form may be used to enroll in benefits instead of the online MyOEBB enrollment system.
 
If you have questions, please call OEBB at (888) 469-6322.
 
 
Enrollment Form

Medicare Creditable and Noncreditable Coverage Notices
 
These notices contain information about current prescription drug coverage with Oregon Educators Benefit Board and about individual's options under Medicare’s prescription drug coverage.
 
If you have questions, please call OEBB at (888) 469-6322.
 
 
 

MyOEBB Forms
 
 
For Education Entities:Click on the link to access the documents, to download, or to print.
 
If you have questions, please call OEBB at 888-469-6322.
 
 
MyOEBB Rules Selection Form
 
MySecurity Access and Access Termination Form
 
 
 

MyOEBB Guides
 
For Education Entities: Click on the link to access the MyOEBB Guides, download, or print.
 
If you have questions, please call OEBB at 888-469-6322.
 
MyOEBB Educational Entity Administrator Guide
 
MyOEBB Imputed Values 
 
MyOEBB New Hire Enrollment Guide 
 
MyOEBB QSC Matrix
 
MyOEBB QSC Detailed Matrix Guide
 
Terminating an Employee by QSC with Benefits Enrollments
 
 

Premium Collection Forms and Documents
 
For Educational Entities:Click on the link to access the premium collection forms and documents for educational entities, download, or print.
 
If you have questions, please call OEBB at 888-469-6322.
 
 
Debit Agreement Form
 
Electronic Funds Transfer Brochure
 
Payment Election Form
 

Reimbursement Forms
 
Click on the link to access the reimbursement forms, download, or print.
 
If you have questions, please call OEBB at 888-469-6322.
 
Reimbursement Form -- Kaiser Permanente
 
Reimbursement Forms -- ODS medical, dental, vision and pharmacy

Transition of Care Forms
 
Click on the link to access the transition of care forms, download, or print.
 
If you have questions, please call OEBB at 888-469-6322.
 
 
ODS Transition of Care
 
Providence Transition of Care

 
Page updated: January 05, 2009

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