Benefits Forms

Medical

• UHC Medical Claim (PDF)
• UHC Medical Claim - International Claims (PDF)
• UHC Disabled Dependent Child Certification

Prescription Drug Program

• Caremark Prescription Claim (PDF)
• Caremark Prescription Mail Order (PDF)
• International Prescription Claim Form (PDF)

Dental Insurance

• Aetna Dental Claim (PDF)

Vision Insurance

• Out-of-Network Claim (PDF) (Form may also be used for in-network claims.)

Flexible Spending Accounts (FSAs)

• PayFlex Claim (PDF)
• FSA Claim Filing Guidelines (PDF)
• Bank of America Claim (PDF)
• Bank of America Letter of Medical Necessity - HCFSA only (PDF)

Health Savings Account (HSA)

• Bank of America HSA User Guide
• Bank of America HSA Contribution Form (PDF)
• Bank of America HSA Transfer Request (PDF)
• Bank of America Identify Verification Form (PDF)

Life Insurance

• Beneficiary Designation (PDF)

Long-Term Disability (LTD)

• LTD Prior Coverage Verification (PDF)

Leave of Absence

• Reporting Your Claim or Leave (PDF)
• Personal Leave Request (PDF)
• Authorization to Return to Work (PDF)

Retirement

• 401(a) Prior Employment Verification Form (PDF)
• 457(b) Salary Reduction Agreement (PDF)

Tuition Remission Benefits

• Tuition Benefits Application (PDF) (For dependents of retirees, university affiliates and dependents of deceased employees only.)
• Graduate Course Certification Form (PDF) (For affiliated groups such as CNMC, NROTC, VA that use the tuition benefit for graduate courses).

Declarations

• Declaration of Common Law Marriage (PDF)
• Declaration of Domestic Partnership (PDF)
• Dissolution of Domestic Partnership (PDF)
• Declaration of Civil Union (PDF)

HIPAA Authorization

Please email [email protected] to request a HIPAA form.