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Forms

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MEDICAL ENROLLMENT FORMS:

CalPERS HBD-12

Pre-tax

DECLINING MEDICAL COVERAGE

CalPERS HBD-12

2026 Cash-In-Lieu

DENTAL & VISION ENROLLMENT FORMS:

Dental & Vision Change in Enrollment form

 

 

 

 

 

 

SELF-PAY 

2026 Self-Pay (Unpaid or Leave Without Pay)

COBRA

COBRA Initial notice

 

HAVE BENEFIT QUESTIONS?

Contact your Benefits Team

Hours: Monday-Friday, 8:30am-5:00pm
Karen Wong
Benefits Specialist
Phone: 925.682.8000 x4152
Laxmi Gurram
Administrative Assistant
Phone: 925.682.8000 x4452
Email: benefits@mdusd.org