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Benefits Forms
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UnitedHealthcare
Select Plus POS and PPO |
UnitedHealthcare Plan
Enrollment Application and Change Form for Select Plus/POS
- Use this form to enroll or make changes in the Select Plus POS Plan.
Out-of-Network Claim Form
- Use this form to submit claims for eligible
health care expenses incurred under the Out-of-Network portion of the
Preferred Provider Organization (PPO) Plan and the Select Plus POS Plan
through United HealthCare. Print out the form, complete it and mail to
United HealthCare Insurance Company, P.O. Box 740800, Atlanta, GA 30374-0800.
Overseas Claim Form for United Healthcare
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Aetna
Health |
Aetna Enrollment and Change Request Form
- Use this form to enroll or make changes in the Aetna Choice POS II Plan.
Aetna Enrollment and Change Request Form
- Use this form to enroll or make changes in the Aetna HMO Plan.
Medical
Benefits Request Form - Retirees should use this form to submit
claims for eligible health care expenses in the Retiree Health Care Plans. |
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Aetna Dental |
Dental Enrollment/Change Form
Dental Claim Form and Instructions -
Mail completed form to: P.O. Box 14094,
Lexington, KY 40512-4094
Dental Service Recruiting Request Form
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MetLife Dental |
Dental Claim Form and
Instructions - Mail completed form to:
MetLife Dental Claims,
P.O. Box 981282,
El Paso, TX 79998-1282
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Medco Health
Prescription Plan |
Medco Health, Direct
Reimbursement Claim Form
Prescription Mail Order Form
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Crosby Benefit Systems, Inc.
Flexible
Spending Accounts |
Health Care
Reimbursement Form - Use this form to request reimbursement of
expenses not covered under your Health Care Plan, such as dental care, vision
care, prescription drug program deductible and copayments. Be sure to include
an Explanation of Benefits or itemized statement from the health care plan.
If you have secondary health care plan coverage under your spouse's health
care plan, use this form to submit any unpaid expenses to your HBEA. Be
sure to include the Explanation of Benefits from your spouse's plan.
Dependent Care Reimbursement Form
- Use this form to
request reimbursement of eligible dependent care expenses (e.g., day care
expenses).
Expense Account Direct Deposit
Authorization Form
Parking Reimbursement Form
Transit
Reimbursement Form
Parking & Transit Reimbursement Account
Add/Change/Termination Form |
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Life Insurance |
Beneficiary Designation
Change Form
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Staff Educational Assistance Plan |
Staff Educational Assistance Plan Application for
Course Approval and Reimbursement:
Effective starting with all 2006 Summer Courses. For prior
reimbursements, call Human Resources at 8-3300.
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Temp Disability |
Application for Short-term Disability
Benefits and Medical Certificate
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Tuition Grant |
Tuition Grant
Application Academic Year 2009-2010
Tuition Grant
Application Academic Year 2008-2009
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Waiver of Service |
Certification of Prior Employment for Waiver of Service
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Supplemental Retirement Plan |
Supplemental Retirement Election Form
Supplemental Retirement Termination Form
Tax Deferred Annuity Plan Salary
Reduction Form
Tax Deferred Annuity Plan Termination Form |
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