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Federal Health Benefits Election Form

Monday, December 11, 2023

Use this form to:

  • Enroll or reenroll in the FEHB Program; or
  • Elect not to enroll in the FEHB Program (employees only);or
  • Change your FEHB enrollment; or
  • Cancel your FEHB enrollment; or
  • Suspend your FEHB enrollment (annuitants or former spouses only).

Complete, print, sign, and return the last two pages of the following form to the DCRB Member Services Center.

You can send the completed forms and any required attachments by fax to (202) 566 -5001 or by mailing your documents to:

DC Retirement Board
Member Services Center
900 7th Street, NW, Second Floor
Washington, DC 20001

If you have further questions, please contact the DCRB Member Services Center by clicking on the Ask Member Services link, or by phone at (202) 343-3272 Monday – Friday from 8:30 am to 5:00 pm.