Employee Benefits Forms

Temporary ID Cards

• 2013 Premium Partners Health Plan Card
• 2013 HSA Health Plan Card
• 2013 Premium Partner Prescription Card
• 2013 HSA Prescription Card
• 2013 Dental

Benefits Enrollment Forms

• New Hire-Status Change Enrollment Form
• Life Event - Qualifying Event Change Form
• 2013 Flexible Spending Enrollment Form
• Life Insurance Beneficiary Designation Form
• MetLife Legal Plan Enrollment Form
• 403(b) Plan Enrollment Form

Health Plan Forms

• Medical Claim Form
• Magellan Claim Form
• Prescription Benefit Mail Order Form
• Prescription Mail Order Form – For Physician 
• Prescription-Direct Member Reimbursement Form
• Tobacco Use Disclosure

Dental Forms

• Dental Claim Form 

Vision Forms

• SightCare Reimbursement Form
• SightCare Temporary ID Form

Life/AD& D Forms

• Life Insurance Application Form
• Life Insurance Beneficiary Designation Form
• Voluntary Life Insurance Portability Form-Group GVTL-9P58

403(b) Forms

• 403(b) Plan Enrollment Form 
• 403(b) Plan Beneficiary Designation Form
• 403 (b) Plan Change and Payroll Deduction Authorization
• 403 (b) Deduction Cancellation Form 

Flexible Spending Account Forms

• 2013 Flexible Spending Enrollment Form
• Additional Flex Debit Card Request Form
• Debit Card Recurring Expense
• Direct Deposit Form
• Reimbursement/Verification Claim Form
• Letter of Medical Necessity

Paid Time Off

• Paid Time Off Donation Form
• Paid Time Off Donation Recipient Form

Leave of Absence and Short Term Disability Forms

• Leave of Absence- Mutual of Omaha- for Employees who need time away from work due to a medical condition, including pregnancy, surgery, in-patient admission or absences of more than 7 calendar days. You need to have been employed at SHC for at least one year and are a Full-Time employee to be eligible for Short Term Disability payments.
•  Leave of Absence- Medical (Self)- for employees who still need time away from work due to your own medical condition, including pregnancy, surgery, in-patient admission or absences of more than 7 calendar days.  If you have not been employed at SHC for one year or are not Full-Time employees but still need to apply for a Leave of Absence you will need to use this form.
• Leave of Absence-Family (adoption, foster care)- when time away from work is due to placement of a son or daughter for adoption or foster care.
• Leave of Absence- Medical (self - intermittent)- when time away from work is due to staff member's own chronic medical condition which causes episodic absences.
• Leave of Absence- Family's Medical Condition- when time away from work is needed to provide care to the staff member's spouse, parent or child, either continuous or intermittent..
• Leave of Absence- Personal & Educational- when time away from work is for personal or educational reasons.
• Leave of Absence- Military - when time away from work is due to Reserve or National Guard Duty, employee who is a covered service member who is on active duty or call to active duty.
• Leave of Absence - Military (Serious Illness) - when time away from work is due to the care for a family member who is a service member with a serious injury or illness.
• Leave of Absence - Military (Qual. Exigency for Military Family)- when time away from work is due to the need of a Family Leave as a family member of a military member who is on active duty or call to active duty.

        Managers Forms Only

• Posting Position - Educational Leave- when a staff member has requested an Educational Leave and the position is being posted by the department.
• Posting Position - FMLA Exhausted- when staff member's FMLA has expired and their position is being posted by department.
• Posting Position - Non-FMLA Eligible- when staff member is Not eligible for FMLA and their position is being posted by department
• Position Not Available - FMLA Exhausted- when staff member's FMLA has expired and their department is not going to fill the position
• Position Not Available - Non-FMLA Eligible - when staff member is Not Eligible for FMLA and the department is not going to fill the position

Worker's Compensation Forms

• Worker's Report of Injury/ Incident
• Supervisor Report of Injury Incident

General Administration Forms

• Adoption Benefit Form
• Bus Pass Application Form
• Domestic Partner Enrollment Form
• Domestic Partner Cancellation Form
• Electronic Disclosure and Consent Form
• Fitness Center Enrollment Form
• Staffing Leave Request Form
• Life Event - Qualifying Event Change Form