Forms

 

Benefits

Health Program Forms

• Faculty, Managers, Coaches, Nurses, and SPFPA Health Program Enrollment Form
• Faculty, Managers, Coaches, Nurses, and SPFPA Student Certification Form
• Faculty Enrollment Forms for Supplemental Benefits
• AFSCME, PSSU, Physicians, and SCUPA Health Program and Supplemental Benefits Forms
• Medco Rx Forms

 

Flexible Spending Account Forms

• Flexible Spending Account (FSA) Enrollment - Medical
• FSA Enrollment Form - Dependent Care
• FSA Status Change Form  
• FSA Reimbursement - Medical
• FSA Reimbursement - Dependent Care

 

Employment

• Annuitant Rehire Request Form
• Employment Eligibility Verification Form (I-9)
• Fair Labor Standards Act (FLSA) Classification Request for SCUPA and Coaches

 

 

HIPAA

• PASSHE HIPAA Authorization Form
• PEBTF HIPAA Authorization Form

 

Insurance (Basic, Voluntary Group Life & Personal Accident, and Long-Term Disability)

Please click here for access to all available PASSHE insurance information and forms

 

Miscellaneous

• Employee Emergency Contact Data Form

 

Payroll
Please direct questions regarding payroll to Dave Kleman in System Human Resources.

• 2008 W-2 Update
• 2009 Paydays and Holidays Calendar
• 2009 Record of Absence
• 2009 W-4 Form
• Decline Paper Pay Statement Authorization Form
• Direct Deposit Authorization Form
• Local Tax (EIT) Form 
• Savings Bond Enrollment Form      
• Previous Periods of Commonwealth Service Form

 

Retirement
Please direct questions regarding retirement to Beth Frey in System Human Resources.

• Retirement Program Election Form
• Alternative Retirement Plan (ARP) Allocation Change Form
• Deferred Compensation Enrollment/Change Form
• Savings Bond Enrollment Form
• TSA Salary Reduction Agreement