Forms & Publications

All Enrollment Benefit Forms will need to be submitted using AdobeSign.

Health Enrollment Forms

• Benefits Worksheet (New Hire)
• Benefits Worksheet ACA 
• Benefits Worksheet (Family Status Change) - PDF, submit via MoveIt. MoveIt instructions are included with the worksheet.

Health

• Affidavit of Marriage/Domestic Partnership
• Affidavit of Parent-Child Relationship (HBD-40)
• Cobra Continuation Election Form
• Domestic Partnership Certification
• Domestic Partnership Taxable Income for Benefits
• Process to Continue Benefits for Disabled Dependent beyond Age 26
• Cobra Continuation Election Form

Vision Plan 

• Vision Reimbursement Form (Out-of-network)
• Vision VDT Claim Form

Other Resources

• Collection of Dependent Social Secuirty Numbers
• HIPAA Authorization to Use and/or Disclose Personal Health Plan Information
• Medical Non-Participating Tax Advantage Premium Plan (TAPP) form

 

• Catastrophic Leave Donation Program (CLDP) Donation Form
• Request for Participation Form
• Summary

• Admission Data Form

Fee Waiver Application: Last name A-L

• Dependent Fee Waiver Application last name A-L
• Faculty and Staff Fee Waiver Application last name A-L
• Career Development Plan (CDP) Form last name A-L

Fee Waiver Application: Last name M-Z

• Dependent Fee Waiver Application last name M-Z
• Faculty and Staff Fee Waiver Application last name M-Z
• Career Development Plan (CDP) Form last name M-Z

Medical Leave Request - Faculty, Staff & MPP

Non-Medical Leave Request - Staff & MPP

Family and Medical Leave (FMLA)

• Employee - Certification of Healthcare Provider
• Family Member - Certification of Healthcare Provider

Catastrophic Leave Donation Program (CLDP)

• Donation Form
• Request for Participation Form

 

Flex Cash Enrollment Form

Flex Cash Brochure

Pre-Tax Parking Deduction Plan Cancellation Form

HCRA and DCRA Enrollment Form 2022

• HCRA and DCRA Claim Form
• ASIFlex Quick Guide
• HCRA Brochure
• DCRA Brochure