ATTACHMENT 1 – INSTRUCTIONS FOR FEHB INFORMATION AND CERTIFICATION 

MEMORANDUM 

The FEHB Information and Certification Memorandum can be used to detail any circumstances 

not readily apparent in the FEHB documentation, such as eligibility for the pre-approved waiver 

of the 5-year coverage rule, coverage as a dependent under another FEHB enrollment, or 

coverage under TRICARE/CHAMPUS. This memo can also be used to document and certify 

that the employee has met the 5-year requirement when sufficient documentation is not available. 

Often, the problem is that the documentation of electronic enrollment changes does not provide 

the old and new plan and effective dates of changes and OPM cannot accurately determine the 

full history of coverage during the 5 years of service immediately prior to retirement (or if less 

than 5 years, during all service in which the employee was eligible for FEHB) from the available 

documentation. Include the memo as the top sheet of the FEHB documentation. 

1. Enter the employee’s name. 

2. Enter the employee’s Social Security Number. 

3. Check the appropriate paragraph for all situations that apply to the enrollee. 

4. Check this paragraph when you do not have full paper documentation to detail coverage 

during the 5 years of service immediately prior to retirement but you can determine that 

the enrollee was covered for entire period. A very common situation is that the printed 

documentation does not reflect both the old and new plans or the effective dates for an 

enrollment change. 

5. For each enrollment change during the 5 years of service immediately prior to retirement, 

enter the new FEHB plan code. 

6. For each change, enter the old plan code. 

7. For each change, enter the effective date of the change. 

8. For each change enter the source(s) of the documentation you used to make your 

determination. The source could be a SF 2809, a record from an on-line enrollment 

system such as Employee Express, or payroll records. As a last resort, if no other records 

are available, agencies can use the Centralized Enrollment Reconciliation Clearinghouse 

(CLER) to search for missing quarters of coverage. 

9. Check this paragraph when the employee was covered as a dependent under another 

enrollment during the 5 years of service immediately prior to retirement. 

10. Check this paragraph when the employee was covered under TRICARE/CHAMPUS as 

the enrollee or a dependent during the 5 years of service immediately prior to retirement. 

11. Check this paragraph when the employee requested an open season change but retired 

prior to the effective date of the enrollment change. 

12. Check this paragraph when the employee is eligible for a pre-approved waiver of the 

participation requirements for continuing FEHB into retirement as set forth in BAL 04-

208. 

13. Check this paragraph and compose a description of any additional information to provide. 

14. Signature of the certifying official. 

15. Date signed by the certifying official. 

16. Enter printed name of the certifying official. 

17. Enter title of the certifying official. 

18. Enter the name of a contact person if additional information is required by OPM. 
19. Enter the phone number of the contact person. 

20. Enter the Email address of the contact person. 
ATTACHMENT 1 – FEHB INFORMATION AND CERTIFICATION MEMORANDUM 

SUBJECT: FEHB Information and Certification Memorandum 

 (1) (2) ______ 

 Employee Name Employee Social Security Number 

(3) As instructed in BALxxx-xx, this memorandum is to notify OPM of the following 

information regarding transfer of the health benefits enrollment for the above employee 

(check any that apply): 

(4) _ Employee retired and is eligible to carry FEHB into retirement. Full documentation for 

the 5 years of coverage is not available. I certify the employee has the 5 years required to 

continue coverage based on the following enrollment actions. All available 

documentation is included. 

New Plan Old Plan Effective Date Source of Documentation (SF 2809, 

Employee Express, CLER, etc.)

 (5) (6) (7) (8)

 

(9) Employee retired, and is eligible to carry FEHB into retirement. Employee was covered 

as a dependent under another FEHB plan for all or part of the 5 years of service 

immediately prior to retirement. Documentation is included. 

(10) Employee retired, and is eligible to carry FEHB into retirement. Employee was covered 

under TRICARE/CHAMPUS either as the enrollee or a family member for all or part of 

the 5 years of service immediately prior to retirement. Employee was covered under 

FEHB on the date of retirement. Documentation is included. 

(11) Employee retired after his/her open season change in enrollment was processed, but 

before the effective date. The SF 2809 is included in the retirement package. 

(12) Employee is eligible for a pre-approved waiver of the participation requirements for 

continuing FEHB into retirement as set forth in BAL 04-208. 

(13) Other: 

_______ (14) ________ _____ (15) ______ ______ (16) _______ ______ (17) ____ 

 Signature Date Printed Name Position Title 

 

 (18) (19) (20) 

Contact Person Phone Number Email Address