General Services Department

Health Care And/Or Dependent Care Flexible Spending Benefits
Section A : GENERAL INFORMATION

The below information is your information, as the employee.
Your Name must match your legal name as reflected on your paycheck
Please fill out all the information below.
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First * Required

Last * Required

Middle

Gender * Required

Male

Female

Mailing Address (Street) * Required

City *

State

Zip *

State Agency (start typing for search and select one option)

Email Address *

Taxpayer ID * Required

SSN (Social Security Number)

ITIN

Taxpayer ID (SSN, ITIN) *

Date of Birth: (mm/dd/yyyy)

Hire Date

Employee ID

	Any person who knowingly and with intent to defraud any insurance company or other person files a statement containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime, Insurance Fraud will be prosecuted to the fullest extent of the law and will prohibit access to RMD Benefits in the future.
	I have had the opportunity to ask questions about my benefit options, have reviewed my enrollment information, and confirm that my elections accurately reflect my informed decisions.
	I understand that once I submit my enrollment information, including any waiver, I will have limited opportunities to change my enrollment elections other than during the open/switch enrollment in the fall of each year for benefit plan years starting each January 1st or with a qualifying event.
	I acknowledge that is my responsibility to notify the provider, at the time of visit, that the care being received is due to a third party.
	I understand that services will be available subject to exclusions, limitations, and conditions described in the summary plan descriptions (found on each carrier’s website). I authorize any hospital, physician, dentist, or other health care provider to furnish, medical information regarding me and my dependents necessary to process claims. I authorize the carrier to coordinate benefits and/or reimbursements with other health or dental plans or insurance companies. I certify that the above information is correct to the best of my knowledge and belief.
	The State’s Group Benefits Plan is required by Federal Law to maintain and protect the privacy of your health information and provide you with notice of its legal duties and privacy practices. The privacy notice is posted at https://www.mybenefitsnm.com/Documents/HIPAA_Policies_and_Procedures_RMD.pdf on the mybenefitsnm.com website. If you have any questions regarding this notice or the privacy of your health information, please contact RMD at PO Box 6850, Santa Fe, NM 87502, or by telephone at 505-827-2036.

Security Code *