Employee Benefits Forms

Temporary ID Cards

• Medical - Prescription - Dental

Health Plan Forms

• Medical Claim Form
• Magellan Claim Form
• Personal Representative 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

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

• 2012 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 have been employed at SHC for at least a year and are eligible for Short Term Disability payments.
•  Leave of Absence- Medical (Self)- for Non Eligible Employees for Short Term Disability payments,(ie. employees who have not been employed with SHC for a full year or part-time).  Use this form if the employee still needs time away from work is due to the staff member's own medical condition, including pregnancy, surgery, in-patient admission or absences of more than 7 calendar days.
• 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 (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- Family's Medical Condition- when time away from work is due to the birth/care for a newborn child or to provide care to the staff member's spouse, parent or child.
• 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,  family member who is a covered service member who is on active duty or call to active duty with a qualifying exigency.
• 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.
• 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
• Critical Illness Application Form
• Domestic Partner Enrollment Form
• Domestic Partner Cancellation Form
• Electronic Disclosure and Consent Form
• Fitness Center Enrollment Form
• Staffing Leave Request Form
• Qualifying Event Change Form