Human Resources » Benefits Forms

Please print the appropriate form(s), fill it out and submit it to the Human Resources Department.

• Adoption Reimbursement Request
• Agreement For Salary Reduction Under Section 403(b)
• Authorization For Payroll Deductions
• Authorization To Release Protected Health Information
• Doctor's Statement of Medical Necessity
• Educational Assistance Application
• Employee X-Ray Referral
• General Notice Of COBRA Continuation Coverage Rights
• Health Savings Plan/Flexible Spending Account Claim for Medical Reimbursement or Dependent Care Reimbursement Form
• Notice Of Privacy Practices
• Personal Representative Designation/Authorization
• Request For Amendment Of PHI
• Request For Confidential Communications
• Request To Access Own PHI
• Request To Inspect Or Copy PHI
• Request To Restrict Certain Uses & Disclosures
• Time Off Request
• Tuition Remission Application
• Tuition Remission Dependent Certification

If you are not sure which form(s) that you should use to meet your needs, please contact our Benefits & Compensation Specialist - Lisa Franczak.

Please click here to go back to the Benefits Information Center.