Form for direct pay retiree, surviving spouse, and COBRA.
Fillable version of the mail service order form for Caremark.
Most agencies submit leave information to ERS monthly. Agencies that do not must complete this form and send to ERS.
Certify children for coverage. (Updated August 2013)
Complete this form if you are diagnosed by a physician as having a health factor that prevents you from discontinuing the use of Tobacco Products. (Updated July 2013)
Use this form to select a primary care physician and to provide other insurance information to your health plan after. (Updated October 2012)
Used to notify ERS that emergency medical attention is needed for a member/dependent(s) coverage NOT shown on carrier’s system. (Updated February 2012)
Participant fills in appropriate sections of the form. The benefits coordinator completes the form and sends to ERS. (Updated February 2012)
200 East 18th Street Austin, TX 78701 ( map)
Toll Free (877) 275-4377
Relay Texas, TTY 7-1-1 or (800) 735-2989