Benefits

Forms relating to Health, Dental, Vision, Hearing, or Prescription programs

• Health Program Enrollment Form - Active Employees
• PASSHE Adult Child Attestation Form - Active Employees
• PASSHE Affidavit of Residence and Dependency for Other Children
• United Concordia Claim Form
• Medco Rx Forms

Flexible Spending Account (FSA)

• Dependent Care Account Claim Form
• FSA Enrollment/Status Change Form
• FSA Letter of Medical Need
• Health Care Account Claim Form

HIPAA

• HIPAA Authorization for Use or Discolosure Form

Insurance

Basic, Voluntary Group Life & Personal Accident, and Long-Term Disability forms can be found here.

Payroll

• Decline Paper Pay Statement Authorization Form
• Direct Deposit Authorization Form
• Local Tax (Earned Income) Form
• Previous Periods of Commonwealth Service Form

Retirement

• Alternative Retirement Program (ARP) Allocation Change Form
• Retirement Program Election Form
• TSA Salary Reducation Agreement Form

Miscellaneous

• Employee Emergency Contact Data Form
• SECA Pledge Form