Health Care & Dental Forms
- Enrollment/Contribution Forms
2018 Enrollment Form for New Hires and Newly Eligible Employees
Complete this form if you are enrolling into your UR Benefits because you were recently hired or recently became newly benefit eligible.2018 Qualifying Event Form
Complete this form if you are enrolling or changing your benefit elections due to a qualifying life event, such as marriage, birth of a child, loss of coverage, etc.HSA Contribution Form
Complete this form if you are enrolling into your HSA, updating your annual contribution to your HSA, or certifying your HSA eligibility.Excellus Young Adult Dependent Through Age 29 Certification Form
To enroll in Special Extended Health Care Coverage through Excellus, the employee and/or employee’s child must complete this enrollment form.Aetna Supplemental Enrollment Information Form
To enroll in Special Extended Health Care Coverage through Aetna, the employee and/or employee’s child must complete this enrollment form.
- Handicapped Dependent Forms
Aetna Handicapped Dependent Form
Complete this form if you are requesting continuation of medical coverage for a disabled dependent and Aetna is your insurance carrier.Aetna Handicapped Dependent Attending Physician's Statement
Complete this form if you need a physician’s statement for your dependent child in the terms of your continuation of medical coverage for a disabled dependent and Aetna is your insurance carrier.Excellus BCBS Handicapped Dependent Form
Complete this form if you are requesting continuation of medical coverage for a disabled dependent and Excellus BCBS is your insurance carrier.
- Claim Forms
Dental Claim Form
Complete this form if you have a dental claim that was not completed by your provider.Aetna Medical Benefits Claims Form
Complete this form if you have a medical claim that was not completed by your provider and Aetna is your insurance carrier.Excellus BCBS Medical Benefits Claims Form
Complete this form if you have a medical claim that was not completed by your provider and Excellus BCBS is your insurance carrier.
- Flexible Spending Account (FSA)
Pay Flex (Aetna) Health Care FSA or Limited Purpose FSA Reimbursement Form
Complete this form if you are filing a claim for your eligible expense for your Health Care FSA or Limited Purpose FSA and Aetna is your insurance carrier.Payflex (Aetna) Direct Deposit Authorization Form
Complete this form if you are setting up a direct deposit account for your FSA account and Aetna is your insurance carrier.Payflex (Aetna) Dependent Care FSA Reimbursement Form
Complete this form if you are filing a claim for your eligible expense for your Dependent Care FSA and Aetna is your insurance carrier.Lifetime Benefit Solutions (Excellus BCBS) Direct Deposit Authorization Form
Complete this form if you are setting up a direct deposit account for your FSA account and Excellus BCBS is your insurance carrier.Lifetime Benefit Solutions (Excellus BCBS) FSA Reimbursement Request Form
Complete this form if you are filing a claim for your eligible expense for your Health Care FSA or Limited Purpose FSA and Excellus BCBS is your insurance carrier.Lifetime Benefit Solutions (Excellus BCBS) Dependent Care FSA Reimbursement Form
Complete this form if you are filing a claim for your eligible expense for your Dependent Care FSA and Excellus BCBS is your insurance carrier. - Health Savings Account (HSA)
HSA Bank Contribution Form
Complete this form if you would like to contribute to HSA Bank (Excellus BCBS members) outside of the contributions that are deducted from your University of Rochester paycheck.HSA Bank Coverage Level Update Form
Complete this form if your plan coverage (single or family) has changed (based on your medical plan coverage) and you need to update it in the HSA Bank system (Excellus BCBS members).HSA Bank Death Beneficiary Form
Complete this form if you would like to add or update a Beneficiary(ies) to your HSA Bank account (Excellus BCBS members).HSA Bank Death Distribution Form
Complete this form if you are the beneficiary of a University of Rochester Employee that is deceased and had an HSA Bank account (Excellus BCBS members).HSA Bank Direct Rollover/Transfer Request Form
Complete this form if you are trying to rollover or transfer funds directly from another HSA or IRA into your HSA Bank account (Excellus BCBS members).HSA Bank Account Distribution Request/Account Closure Form
Complete this form if you are trying to transfer money out of you HSA Bank account into another account or trying to close your HSA Bank account (Excellus BCBS members).PayFlex HSA Account Closure Form
Complete this form if you are trying to close your PayFlex account (Aetna members).PayFlex HSA Beneficiary Designation Form
Complete this form if you would like to add or update a Beneficiary(ies) to your PayFlex account (Aetna members).PayFlex HSA Request for Return of Excess Contributions or Request to Close HSA Opened in Error Form
Complete this form if you are requesting to return excess contributions or Request to Close an HSA Opened in error (Aetna members).PayFlex HSA Transfer Request Form
Complete this form if you are trying to rollover or transfer funds directly from another HSA or IRA into your PayFlex account (Aetna members). - Domestic Partner Forms
University of Rochester Certification of Domestic Partner Status Form
Complete this form if you are adding a Domestic Partner as a dependent to your medical or dental plan.University of Rochester Domestic Partner (opposite-sex and same-sex) Tax Affidavit
Complete this form if you are adding a Domestic Partner as a dependent on your medical or dental plan and you require a tax affidavit.
- Pharmacy Forms
MAC Penalty Exception Request Form
Complete this form if you are requesting for drug evaluation penalty exception.
Click here for a full list of forms regarding University Benefits.