Georgia Emerging Infections Program
Georgia Department 
Human Resource Forms and Downloads
Health Insurance Forms
If you experience a qualifying event, you may be able to make changes for yourself and your dependents, provided you request the change within 31 days of the qualifying event. For a complete list of qualifying events refer to the 2009 Decision Guide. Request must be made within 31 days. DO NOT HOLD FORM FOR VERIFICATION DOCUMENTATION.
2009 EE Enrollment/Transfer Form
This form is to be used only for New enrollees or New employees hired or enrolling after 12/31/08.
Change and Miscellaneous Update Form
Must be completed by each eligible employee who wishes to enroll or change coverage option or type in any option offered by the SHBP. This form should be used for updating information such as address, or adding or deleting dependents to an existing family contract with the SHBP.
Over Age Dependent Coverage
Dependent Student Status Information
Use this form to update the status of a dependent child who is over the age of nineteen for coverage as a full-time student. An update is required every twelve months if the member desires to keep a valid identification card showing the student as a covered dependent.
Decline or Discontinue Coverage
Declination of Health Benefit Coverage
Use this form when an employee declines coverage upon employment or is ineligible for coverage due to employment status (e.g., part-time employees).
Discontinuation of Health Benefit Coverage
Request to Continue Health Benefits During Leave of Absence Without Pay
This form must be submitted by the employee to continue health benefits during a leave of absence without pay.
Disability Certification
This form must be submitted with the request to continue health benefits during a leave of absence without pay due to a disability, including disability for the use of family leave (FMLA).
Surcharges - Spousal and Tobacco
Spousal Surcharge Form
Use this form to remove a spousal surcharge when spouse is not eligible or is enrolled for health coverage through their employer.
Non Tobacco User Affidavit Form
Use this form to remove tobacco surcharge if you and all covered dependents are non-tobacco users (e.g., failed to answer surcharge questions during OE).
Tobacco Cessation Affidavit for All Other Options
Tobacco Users Cessation Policy and Classes
Flexible Benefits
The GaBreeze Web site is the one place for you to go
to ask questions, get help making decisions and enroll in or make changes
to your Flexible Benefits. You
can reach the site from work, home, or wherever you connect to the
Internet.
The GaBreeze Web site makes it easy for you to get
the benefits information you and your family need and take action
throughout the year. This
secure, password-protected Web site is the way to:
- Learn about your Flexible Benefits and coverage
details.
- Find a dental or vision provider in your
network.
- Access your Flexible Benefits provider’s Web
site.
- View a summary of your Flexible Benefits
coverage.
- Access claim forms and benefit Summary Plan
Descriptions.
- Designate or update your beneficiaries.
- Make changes during the year when you have
experienced a qualifying change in status.
- Use special tools to help you compare your
benefit choices for features and prices.
- Provide feedback on or contact the GaBreeze
Benefits Center.
GaBreeze Web site:
www.gabreeze.ga.gov
You may also contact the GaBreeze Benefits Center
toll-free at 1-877-342-7339 (1-877-GBreez).
Representatives are available to assist you Monday through Friday
from 8:00 a.m. to 5:00 p.m., Eastern Standard Time.
GaBreeze Employee Quick Reference Guide
Check your home address.
An outdated or incorrect address could prevent you from receiving
important benefit information that is mailed to your home.
If any changes to your address are required, you need to notify the
District Personnel Department.
In order to change your address on your Flexible Benefits, please complete
the Flexible Benefits Change of Address form and forward to the District
Personnel Department.
Change of Address Form - Flexible Benefits
Debbie Neighbors
Personnel Manager
Northwest Georgia Public Health
1309 Redmond Road, NW
Rome, Georgia 30165-9655
Phone: 706-295-6648
Fax: 706-802-5047
djneighbors@dhr.state.ga.us
