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Forms","

Brief Description

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2024 Current Employee with Adult Child Notice

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Notification and enrollment form for adult dependent children ages 26-30 in available health plans. Applicable to adult children aging off at the end of the month in which they turn age 26 or new enrollment due to lost of other health coverage (status change). Additional premium required.

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2024 Retiree with Adult Child Notice

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Notification and enrollment form for adult dependent children ages 26-30 in available health plans. Applicable to adult children aging off at the end of the month in which they turn age 26 or new enrollment due to lost of other health coverage (status change). Additional premium required.

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Authorization For Release Of Health Information (HIPAA) Form

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Interactive form allowing person authorized by employee to address benefits concerns

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Benefits Department Data Request Form

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Deletion Form

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Interactive form used to remove/delete dependents and/or change participation levels (Restrictions Apply)

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Dependent Verification Form & FAQ

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To verify an eligible dependent(s) prior to enrollment into the Health, Dental and Vision Coverage, in compliance with the District's Dependent Verification Process.

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Domestic Partner Enrollment Forms

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Interactive Insurance Enrollment Forms and information for adding a domestic partner and dependents

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Disenrollment Statement - Domestic Partner

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Interactive Insurance Disenrollment Form for deleting a domestic partner and dependents

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EAP Formal Referral Form

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Interactive Referral Form used by Administrators/Supervisors to request EAP Assistance

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Evidence of Insurability Application - Life Insurance

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Application used to request enhancement of Life Insurance.

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FMLA Application-Instructional Personnel

FMLA Application Non-Instructional Personnel

FMLA Certification - Employee

FMLA Certification - Family Member

FMLA Certification - Exigency Military

FMLA Certification - Current Military

FMLA Certification - Veteran Military

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Interactive Application used to request Family Medical Leave - Administrative and Non-Instructional Personnel When submitting an application for FMLA the applicable certification form must be completed and sent directly to the Leaves DepartmentThere are five (5) different certification forms, depending on which leave is being selected. All certification forms must be completed by physician or practitioner and employee. 

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HIPAA Release Form

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Authorization For Release of Health Information

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Leave of Absence Request 

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Interactive Application for Board Approved Leave of Absence .

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Medco Mail-Order Prescription Form

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Form used to order prescriptions via mail-order service from Medco.

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Medco Mail-Order Prescription Refill Form

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Form used to order refill of prescriptions via mail-order service from Medco.

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Newborn Enrollment Form

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Interactive form

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Opt-Out | Dental

Opt-Out | Medical

Opt-Out | Vision

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Interactive forms used to request a declination of Medical, Dental and Vision Insurance Coverage for School Board Employee.

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MetLife Absence Reporting Guide

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Instructions for filing a (MetLife) disability claim by telephone

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Mutual of Omaha Designation of Beneficiary Form

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Interactive form 

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Mutual Of Omaha Life Insurance Portability Request Form

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Interactive form used to continue term life insurance within 60 days of employee's termination.

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Status Change Form

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Interactive form used to add/enroll dependent(s) and/or change participation levels (Restrictions Apply).

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Supplemental Deletion Form

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 Interactive form utilized for cancellation of supplemental insurance.

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Vision - Humana CompBenefits Out of Network Reimbursement Form

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Interactive form utilized for reimbursement of Out-of-Network Vision Care Claims

"]]" id="hidData59064">