JHU Benefits Site - Forms

Forms

Here you will find almost any benefits form you might need. Just print a copy of the form, complete it, and then submit it as instructed.

Forms will download as PDF or DOC files, which you can open with the latest versions of Adobe Acrobat Reader and Microsoft Word, respectively.

Medical Plans
Benefit Plan Contact Form Use For...
 
CareFirst BlueCross
BlueShield
CareFirst BCBS Major Medical Claim Form Submitting U.S. medical claims
International Claim Form Submitting international medical claims
CareFirst BCBS Disability Qualification Questionnaire Verifying your disabled dependent’s eligibility for coverage under the CareFirst BCBS medical plan
EHP Medical/Vision Claim Form Submitting medical and vision claims
Express Scripts Health Solutions - Pharmacy Mail Order Form Ordering medications through the mail order pharmacy
Prescription Drug Reimbursement Form Applying for 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
Benefit Plan Contact Form Use For...
 
Cigna Cigna Dental Claim Form Submitting dental claims
CareFirst BCBS CareFirst Dental Claim Form Submitting dental claims

Flexible Spending Accounts
Benefit Plan Contact Form Use For...
 
WageWorks Flexible
Spending Accounts
Health Care Pay-Me-Back Form Applying for reimbursement of eligible out-of-pocket health care expenses
Dependent Care Pay-Me-Back Form Applying for reimbursement of eligible out-of-pocket dependent care expenses
Pay-My-Provider Applying for payment directly to provider

Complete this form on the WageWorks site at http://www.wageworks.com/

First time user? When you register, you will create your own password for convenient 24/7 online access to your accounts

Life, Travel & Personal Accident Insurance Plan
Benefit Plan Contact Form Use For...
 
MetLife Group Life Insurance Beneficiary Designation Form Use when making changes to your beneficiary designation
Life Insurance Conversion Form Retaining your life insurance coverage if you leave JHU
Accelerated Benefits Option Form Requesting the accelerated life insurance option for terminal employee (less than 12 months to live)
The Hartford Personal Accident and Group Travel Accident Insurance Beneficiary Designation Form Designating a beneficiary
Association Insurers Agency Personal Accident Insurance Conversion Form Retaining your personal accident insurance coverage if you leave JHU
  Contact the Benefits Service Center for a Statement of Health Form

Disability Protection
Benefit Plan Contact Form Use For...
 
The Hartford Long Term Disability Claim Form Applying for long term disability
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
Long Term Disability Conversion Form Retaining your LTD coverage if you leave JHU

Tuition Assistance
Benefit Plan Contact Form Use For...
 
Tuition Remission Applications Faculty and Staff Tuition Remission Plan Application Applying for tuition remission for part-time studies and professional development courses
Spouse/Same Sex Domestic Partner Tuition Remission Plan Application
Dependent Child Tuition Remission Plan Application
Tuition Remission for Continuing Education Courses Outside of JHU Application
Tuition Reimbursement Applications Tuition Reimbursement Plan Application for Faculty and Staff Applying for tuition reimbursement for part-time undergraduate studies outside JHU

Faculty/Staff who live and work outside the Baltimore/Washington metropolitan area may also submit tuition reimbursement for part-time graduate studies outside of JHU
Tuition Reimbursement Plan Application for Bargaining Unit Members
Tuition Grant Application Tuition Grant Plan Application Applying for tuition grant for dependent children for full-time studies
Dependent Expense Form Document dependent status if student is not a tax dependent.
Disabled Dependent Exception Form Requesting an exception to tuition grant eligibility on basis of dependent's disability
Study Abroad Certification Letter Obtaining certification for tuition grant dependent to study abroad

Retirement Plans
Benefit Plan Contact Form Use For...
 
403(b) Retirement Plan 403(b) Contribution Agreement for Faculty & Staff Participating in 403(b) Plan: F/T and P/T Faculty, Visiting Faculty, Sr. Staff, Support Staff, Bargaining Unit
403(b) Retirement Plan 403(b) Contribution Agreement for Casual or Limited-time Positions Participating in 403(b) Plan: Casual, Limited-Time Positions
Income Deferral Plan for Residents, Interns, and Postdoctoral Fellows Income Deferral 403(b) Contribution Agreement Participating in 403(b) Plan: Residents, Assistant Residents, Interns, Postdoctoral Fellows
403(b) Enrollment Fidelity
TIAA-CREF
The Vanguard Group
Opening an account with an investment company
Prudential Support Staff
Pension Plan
Designation/Change of Beneficiary Form Designation/Change of Beneficiary Form

Other Forms
Benefit Plan Contact Form Use For...
 
Adoption Assistance Plan Adoption Assistance Plan Form Applying for 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