You’ll find important benefits forms below. Just print a copy of the form, complete it, and then submit it as instructed.
Forms will download as .PDF or .DOC files, which you can open with the latest versions of Adobe Acrobat Reader and Microsoft Word, respectively.
| Benefit Plan | Form | Use for… |
|---|---|---|
| Medical Plans | ||
| CareFirst Administrators | CareFirst Administrators Medical Claim Form | Submitting medical claims for service received in the United States |
| CareFirst Administrators International Medical Claim Form | Submitting medical claims for service received outside the United States, Puerto Rico and the U.S. Virgin Islands | |
| CareFirst Administrators Disability Certification for Over-age Dependents | Verifying your disabled dependent’s eligibility for coverage under your CareFirst medical plan | |
| Capital Rx | Prescription Drug Claim Form | Submitting a claim for prescription drugs paid for out of pocket |
| Dental Plans | ||
| Delta Dental | Delta Dental Claim Form | Submitting dental claims |
| Flexible Spending Accounts | ||
| WEX Flexible Spending Accounts | Pay-Me-Back Claim Form | Applying for reimbursement of eligible out-of-pocket health care expenses |
| Pay-My-Provider Visit WEX to complete the form to pay your provider | Applying for payment directly to provider | |
| Tuition Assistance | ||
| Tuition Remission Applications | Faculty, Staff and Bargaining Unit Tuition Remission Plan Application | Applying for tuition remission for part-time studies, professional development, and personal enrichment courses taken at JHU |
| Spouse/Domestic Partner Tuition Remission Plan Application | ||
| Dependent Child Tuition Remission Plan Application | ||
| Retiree Tuition Remission Plan Application | ||
| Tuition Remission for Continuing Education Courses Outside of JHU Application | Applying for tuition remission for CEUs taken outside of JHU | |
| Tuition Grant Applications | EdAssist | Applying for tuition grant for dependent children for full-time studies |
| Dependent Expense Form | Documenting dependent status if student is not a tax dependent | |
| Disabled Dependent Exception Form | Requesting an exception to tuition grant eligibility on basis of dependent’s disability | |
| Study Abroad Certification Letter | Obtaining certification for tuition grant dependent to study abroad | |
| Tuition Assistance | Tuition Assistance Repayment Agreement | Repaying an overpayment of tuition assistance as outlined in the Tuition Assistance Policy |
| Retirement Plans | ||
| Empower/Prudential Pension Plan | Designation/Change of Beneficiary Form | Designating or changing pension beneficiary |
| Other Forms | ||
| Adoption Assistance Plan | Adoption Assistance Plan Form | Applying for reimbursement of eligible adoption expenses |
| Gestational Surrogacy Program | Gestational Surrogacy Form & Affidavit | Applying for reimbursement of eligible expenses associated with gestational surrogacy |
| Marriage or Domestic Partnership | Affidavit of Marriage/Domestic Partnership | Verifying marriage or domestic partner relationship |
| Termination of Domestic Partnership | Verifying termination of domestic partner relationship | |