INSTRUCTIONS: ALABAMA RETIREE EMPLOYMENT VERIFICATION (Form PEEHIP REV)
A form PEEHIP REV is used to verify the employment statue of a retiree enrolled in the Alabama Public Education Employees' Health Insurance Plan (PEEHIP). This document can be obtained from the website of the Retirement Systems of Alabama.
Alabama Retiree Employment Verification PEEHIP REV Step 1: The first section concerns the PEEHIP subscriber. On the first line, enter the subscriber's Social Security number, first name, middle name or initial and last name.
Alabama Retiree Employment Verification PEEHIP REV Step 2: On the second line, enter the subscriber's mailing address, city, state and zip code.
Alabama Retiree Employment Verification PEEHIP REV Step 3: On the third line, enter the subscriber's home phone number.
Alabama Retiree Employment Verification PEEHIP REV Step 4: The next section concerns your employment. Indicate with a check mark whether you are employed. If no, skip to the Medicare section beneath.
Alabama Retiree Employment Verification PEEHIP REV Step 5: On the first line, enter the name of your current employer, their phone number, and your date of hire.
Alabama Retiree Employment Verification PEEHIP REV Step 6: On the second line, enter your employer's address, city, state and zip code.
Alabama Retiree Employment Verification PEEHIP REV Step 7: Indicate whether your employer offers group health insurance with a check mark. If no, skip to the Medicare section below.
Alabama Retiree Employment Verification PEEHIP REV Step 8: Indicate whether your employer contributes at least 50% or more of single health insurance coverage for employees. If no, skip to the Medicare section below.
Alabama Retiree Employment Verification PEEHIP REV Step 9: Indicate whether you are eligible for your employer's group health insurance coverage with a check mark. If yes, enter the date on which you are eligible. If no, explain.
Alabama Retiree Employment Verification PEEHIP REV Step 10: The next section concerns Medicare. Indicate whether you are eligible with a check mark.
Alabama Retiree Employment Verification PEEHIP REV Step 11: If you or your dependents are eligible for Medicare, the next section must be completed. Enter the name, Medicare card number, and effective date for the subscriber. Additionally, indicate with a check mark whether you are eligible for Part A, Part B or Part D.
Alabama Retiree Employment Verification PEEHIP REV Step 12: Sign and date the form where indicated.