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Benefits Forms

Medical

• 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 - Medical & Dental Plan Enrollment & Change Form
  • Summary of Benefit Coverage (SBC) for All Medical Plans
• FCPS -Health Plan Eligibility & Deduction Authorization for Both Spouse Employees
• FCPS Dependent Affidavit

Dental

• Aetna - Dental Benefits Request (for pretreatment of claim)
• Aetna - Dental Claim
• FCPS - Medical & Dental Plan Enrollment & Change Form
• FCPS Dependent Affidavit

Vision

• UnitedHealthcare Vision Out-of-Network Claim Form

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

Disability Certification for Over-age Dependent

• CareFirst – Disability Certification for Over-age Dependent
• Kaiser Permanente - call 301-468-6000
• 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)

Flexible Spending Account Forms (ADP)

• FSA Enrollment/change form
• Dependent Care Claim Form
• Health Care Claim Form

Long-Term Care Insurance

• Application Instructions for CNA Enrollment Form and CNA Short Form
  • CNA Enrollment Form for employees who enroll within 30 days of hire date
  • CNA Short Form for spouses enrolling anytime, or employees enrolling after 30 days
• Application Instructions for Long Form
  • CNA Long Form for employee's parents, grandparents, in-laws, and retirees to enroll

Life Insurance

Enrollment and Beneficiary Designation

• Minnesota Life for members of FCERS
• Evidence of Insurability Form for members of FCERS (mail directly to address on form)
• Enrollment Application for VRS Optional Group Life Insurance
• Minnesota Life for members of VRS- Designation of Beneficiary
• Evidence of Insurability form for members of VRS (mail directly to address on form)

Conversion coverage (for terminating employees)

• Minnesota Life for members of FCERS
• Minnesota Life for members of VRS

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 Form (to continue your FCPS benefits while 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 Certification Form

403(b)

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

What's New in Benefits

• Express-Scripts.com has made some upgrades to online services. Notice of changes. Visit the Express Scripts summary page.
• Will your family be growing soon? See the Maternity/Paternity checklist to make sure your benefits and leaves forms and requests are submitted in time!
• Thrive! is back. If you are participating remember to log your minutes daily!