Benefits Forms

Navigate to find the following categories of forms on this page:

Flexible Spending Account (FSA) Reimbursement Forms

You can submit your claims online, via the mobile app or on paper. To submit on paper, please use these forms:

Medical, Dental, Vision & Prescription Reimbursement Forms

To submit a claim for reimbursement for dental, vision and prescription services, visit these websites:

Forms for Newly Benefit-eligible Employees

Mid-year Change Forms for Qualifying Events

The following forms and information must be delivered to the Human Resource Department within 31 days of the date of the qualifying event.

  • Benefit Change Request
  • Proof of Dependent Eligibility (Required to enroll or re-enroll any dependents)
  • Document showing proof of qualifying event, such as a birth certificate, marriage certificate, divorce papers, or certificate of creditable coverage showing loss or gain of coverage.

Life Insurance Forms

Use the form below to update your life insurance beneficiaries at any time during the year.

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    Drs. Voelker and Lobosky honored with 2014 Physician Legacy Award

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    Drs. Voelker and Lobosky honored with 2014 Physician Legacy Award

  • video-img

    Drs. Voelker and Lobosky honored with 2014 Physician Legacy Award

  • video-img

    Drs. Voelker and Lobosky honored with 2014 Physician Legacy Award

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