Benefits Forms

Information about Benefits Forms and Supporting Documentation

Medical Enrollment & Change Form

  • HR-124

    Medical & Dental Enrollment and Change Form

FCPS Health Plan Eligibility & Deduction Authorization for Both Spouse Employees

  • HR-134

    Spouse Health Plan Eligibility and Deduction Authorization, both spouses employees

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

Family Medical Leave (FMLA)

  • HR-126

    Request for a Foreseeable Family Medical Leave

  • HR-146

    Certification of Health Care Provider for Employee's Serious Health Condition (Family and Medical Leave Act)

  • HR-147

    Certification of Health Care Provider for Family Member's Serious Health Condition (Family and Medical Leave Act)

  • HR-148

    Certification for Serious Injury or Illness of Covered Servicemember--for Military family Leave (Family and Medical Leave Act)

  • HR-149

    Certification of Qualifying Exigency for Military Family Leave (Family and Medical Leave Act)

Flexible Spending Account (FSA)

Integrated Disability Management

Leave of Absence

  • HR-136

    Request for an Unpaid Long-Term Leave of Absence

Life Insurance: Securian Financial for members of FCERS

Life Insurance: Securian Financial for members of VRS

Retirement Forms

Request to Transfer Unused Sick Leave to Fairfax County Public Schools

  • FS73-07

    Request to Transfer Unused Sick Leave to Fairfax County Public Schools

457(b)

Hybrid 457