Benefits Forms for Employees

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• CareFirst – Health Benefits Claim (For MD, DC and Northern Virginia service area)
• CareFirst - Health Benefits Claim (Out of Area) (For all other service areas)
  
• FCPS - Employee Medical Plan Enrollment & Change Form
  • Documentation for Midyear Benefit Changes
• FCPS - Spouse Health Plan Deduction

Prescription Drugs Through Express Scripts (CareFirst only)

• Express Scripts – Mail Pharmacy Service (form not available online, please call HR Service Center at 571-423-3000
• Express Scripts – Prescription Drug Claim
• Express Scripts – Prior Authorization Medication Request

Dental

• Aetna - Dental Benefits Request (for pretreatment of claim)
• Aetna - Dental Claim
• FCPS - Dental Enrollment & Change Form for Employees and Retirees
  • Documentation for Midyear Benefit Changes

Disability Certification for Overage Dependent

• Aetna Dental - must complete two forms:
  • Request for Continuation of Dental Coverage For Handicapped Child (employee form) and
  • Handicapped Child Attending Physician’s Statement (physician form)
• CareFirst – Disability Certification for Overage Dependent
• Kaiser - contact Kaiser at 301-468-6000

Flexible Spending Account Forms (FBMC)

• Change in Status form
• Direct Deposit form
• Enrollment form
• Information about Reimbursements
• Letter of Medical Need
• Over the Counter Expenses
• Reimbursement form

Long Term Care Insurance

• Application Instructions for CNA Enrollment Form and CNA Short Form
  • CNA Enrollment Form - for employees who enroll during their first 30 days after being hired
  • CNA Short Form - for spouses who enroll at anytime, and employees enrolling outside of their 30 day initial enrollment period
• Application Instructions for Long Form
  • CNA Long Form - for parents and grandparents and in-laws of employees who wish to enroll

Life Insurance

• Canceling Optional Life Insurance (all plans)
• Enrollment and Beneficiary Designation
  • County Life (FCERS members)
  • Minnesota Life (VRS members)

Family Medical Leave (FMLA)

• Form A - Request for a Foreseeable Family Medical Leave
• Form B - Response to Employee Request for a Foreseeable Family Medical Leave
• Form C - Notice to Designate Authorized Employee Absences as Family Medical Leave
• Form D - Certification of Health Care Provider for Employee's Serious Health Condition
• Form E - Certification of Health Care Provider for Family Member’s Serious Health Condition
• Form F - Certification for Serious Injury or Illness of Covered Servicemember – for Military Family Leave
• Form G - Certification of Qualifying Exigency For Military Family Leave

Leave of Absence

• Request for Leave of Absence form
• Benefit Billing Election (to continue your FCPS benefits while you are on a Leave of Absence)

HIPAA

• FCPS – Medical, Dental and Health Care Flexible Spending Account (FSA) HIPAA Plans’ Authorization (for the Use or Disclosure of Protected Health Information)

Retirement Forms

• Retirement Forms available at FCERS, ERFC, VRS
  • FCERS Retirement Plan Election Form
• Deferred Health Option Form

Integrated Disability Management

• Fitness for Duty Form

403(b)

• Salary Reduction Agreement
• Transaction Routing Request Form
• 401(k) Financial Hardship Rules applicable to 403(b)
• 403(b) Hardship Withdrawal Disclosure