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Forms
Here you will find almost any benefits form you need. Just click on the name of the form and hit "print" to send it to your printer. Once you have a printed copy of the form, fill it out and submit as instructed on the form. Forms are grouped by type of benefit.
- Medical
- Dental
- Flexible Spending Accounts
- Life, Travel & Personal Accident Insurance Plan
- Disability Protection
- Tuition Assistance
- Retirement Plans
- Other Forms
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| Name of Plan | Name of Form | Use for... |
|---|---|---|
| MEDICAL PLANS | ||
| CareFirst BlueCross BlueShield | CareFirst BCBS Major Medical Claim Form | Submitting Claims |
| CareFirst BCBS Disability Qualification Questionnaire | Verification that your disabled dependent is eligible to be covered under the plan | |
| EHP | Medical/Vision Claim Form | Submitting medical and vision claims |
| BlueChoice | BlueChoice Member Application and Physician Selection | Applying for benefits and selecting a primary doctor |
| Kaiser Permanente | Kaiser Permanente Enrollment Application and Change Form | Enrolling or changing coverage | Medco Health Solutions -- Pharmacy | Mail order form | Ordering medications through the mail order pharmacy |
| Prescription Drug Reimbursement form | Reimbursement of prescription drug claims | |
| Other Medical Forms | Medical Waiver Form | Providing documentation of other health insurance in order to waive coverage through JHU |
| DENTAL PLANS | ||
| CIGNA | CIGNA Dental Claim Form | Submitting Dental Claims |
| CareFirst | CareFirst Dental Claim Form | Submitting Dental Claims |
| FLEXIBLE SPENDING ACCOUNTS | ||
| WageWorks Flexible Spending Accounts | Health Care Pay-Me-Back Form | Reimbursement of eligible health care expenses paid out-of-pocket |
| Dependent Care Pay-Me-Back Form | Reimbursement of eligible dependent care expenses paid out-of-pocket | |
| Pay-My-Provider | This online form may be completed on the WageWorks site at www.wageworks.com. First time user? When you register, you will create your own password for convenient online access to your accounts 24/7. | |
| LIFE, TRAVEL & PERSONAL ACCIDENT INSURANCE PLANS | ||
| Group Life Insurance Beneficiary Designation Form | Enrolling in the plan and designating a beneficiary | |
| Life Insurance Conversion Form | Keeping insurance if you leave JHU | |
| Personal Accident and Group Travel Accident Insurance Beneficiary Designation Form | Designating an Beneficiary | |
| Statement of Health Form | Verifying Evidence of Insurability | |
| DISABILITY PROTECTION | ||
| Long Term Disability Claim Form | Submitting a long term disability claim | |
| Reporting a Short Term Disability Claim | How and when to report a short term disability claim | Certificate of Previous LTD Coverage | Documenting eligibility for waiver of one-year waiting period |
| TUITION ASSISTANCE | ||
| Tuition Remission Applications | Faculty and Staff Tuition Remission Plan Application | Apply for tuition remission for part-time studies and professional development courses. |
| Spouse / Same Sex Domestic Partner Tuition Remission Plan Application | ||
| Dependent Child Tuition Remission Application | ||
| Tuition Grant Application | Tuition Grant Plan Application | Apply for tuition grant for dependent children for full-time studies. |
| RETIREMENT PLANS | ||
| 403(B) Retirement Plan | Authorization for Salary Reduction & University Contribution Agreement | Eligible for Univ. Contribution Sr. Staff & Faculty < age 35 w/ 2+ yrs service or age 35 or older Support Staff & Bargaining Unit 2+ yrs service |
| Authorization for Salary Reduction Agreement | Not eligible Sr. Staff & Faculty < age 35 w/ < 2yrs service Support Staff & Bargaining Unit < 2 yrs service |
|
| Income Deferral Plan for Residents, Interns, and Postdoctoral Fellows | Authorization for Salary Reduction & University Contribution Agreement Residents, Assistant Residents and Interns | Residents, Assistant Resident & Intern contribution. |
| Authorization for Salary Reduction Agreement for Postdoctoral Fellows | Postdoctoral Fellows contributions. | |
| Support Staff Pension Plan | Designation / Change of Beneficiary Form | Designating or changing a beneficiary. |
| OTHER PROGRAMS | ||
| Adoption Assistance Plan | Adoption Assistance Plan Form | Reimbursement of eligible adoption expenses |
| Marriage or Same-Sex Domestic Partnership | Affidavit of Marriage / Same-Sex Domestic Partnership | Verifying marriage or same-sex domestic partner relationship |
| Termination of Marriage / Same-Sex Domestic Partnership | Verifying divorce or termination of marriage or same-sex domestic partner relationship | |