Health Care & Dental Forms

If you need to submit a Total Rewards form: please download, electronically complete, and email back to totalrewards@rochester.edu. If a form is mailed in, the process will be prolonged and will cause significant delay. If you have any questions or need additional help, please email totalrewards@rochester.edu.

• Enrollment/Contribution Forms

  Please use one of the forms below if you are electing or changing (through a qualifying event) your health and/or dental benefits for 2020. Once you have completed and signed the form, please send in all pages of the form to Totalrewards@rochester.edu. If you are a new hire (not newly eligible) you are encouraged to enroll in your benefits online through HRMS.

  • 2021 Enrollment Form for New Hires and Newly Eligible Employees
  • 2020 Enrollment Form for Residents & Fellows
  • 2021 Enrollment Form for Members of SEIU
  • 2021 Qualifying Event Form
  • 2020 Qualifying Event Form - Please use this form if your qualifying event occurred in 2020

  
  

  2021 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.

  
  
• Handicapped Dependent Forms

  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)

  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.

  Pay Flex (Aetna) Health Care FSA, Limited Purpose FSA, or Dependent Care 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.

• 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 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 Direct Transfer Request Form
  Complete this form to authorize HSA Bank to receive a transfer of assets directly from a Health Savings Account (HSA) into your HSA at HSA Bank.

  HSA Bank Rollover Request Form
  Complete this form for an HSA Rollover involving a check.

  HSA Bank Name Change Request Form
  Complete and remit this form if requesting a name change. Required: Please attach supporting documentation of the name change such as a copy of a marriage certificate, divorce decree, or a court order for the name change.

  PayFlex HSA Account Closure Form
  Complete this form if you are trying to close 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.