Retiree Benefits Forms

Information about Benefits Forms and Supporting Documentation

Medical & Dental Enrollment and Change Form for Retirees

  • HR-461

    Medical & Dental Enrollment and Change Form for Retirees

FCPS Dependent Affidavit (if needed)

  • FCPS Dependent Affidavit

    This form is used to affirm that a dependent is eligible for coverage under a participant's FCPS health plan.

Dental

Disability Certification for Over-age Dependent

  • Aetna: Disability Certification for over-age dependents (must submit both forms)
    • Request for Continuation of Coverage For Disabled Child
    • Disabled Child Attending Physician’s Statement
  • CareFirst: Disability Certification for Over-age Dependent
  • Kaiser Permanente: Call 301-468-6000

Aetna: Request for Continuation of Coverage for Disabled Child (Employee Form)

Aetna: Disabled Child Attending Physician’s Statement (Physician Form)

CareFirst: Disability Certification for Over-age Dependent