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.
| Medical Plans (2024) | ||
|---|---|---|
| Benefit Plan Contact | Form | Use For… |
| 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 Overage 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 |
| Medical Plans (Prior to 2024) | ||
|---|---|---|
| Benefit Plan Contact | Form | Use For… |
| CareFirst BlueCross BlueShield |
CareFirst BCBS Health Benefits Claim Form | Submitting U.S. medical claims |
| International Claim Form | Submitting international medical claims | |
| CareFirst Disability Certification for Overage Dependents | Verifying your disabled dependent’s eligibility for coverage under the CareFirst BCBS medical plan | |
| EHP | Medical/Vision Claim Form | Submitting medical and vision claims |
| EHP Disabled Dependent Form | Applying for your adult disabled dependent’s coverage under the EHP plan | |
| Express Scripts Health Solutions – Pharmacy | Mail Order Form | Ordering medications through the mail order pharmacy |
| Prescription Drug Reimbursement Form | Applying for reimbursement of prescription drug claims | |
| Dental Plans | ||
|---|---|---|
| Benefit Plan Contact | Form | Use For… |
| Delta Dental | Delta Dental Claim Form | Submitting dental claims |
| Flexible Spending Accounts | ||
|---|---|---|
| Benefit Plan Contact | Form | Use For… |
| WEX/Discovery Benefits Flexible Spending Accounts | Discovery Benefits Pay-Me-Back Claim Form | Applying for reimbursement of eligible out-of-pocket health care expenses |
| Pay-My-Provider | Applying for payment directly to provider
Complete form on the WEX/Discovery Benefits site at wexinc.com |
|
| Disability Protection | ||
|---|---|---|
| Benefit Plan Contact | Form | Use For… |
| Lincoln Financial Group
|
Certificate of Previous LTD Coverage | Documenting eligibility for waiver of one-year waiting period |
| Tuition Assistance | ||
|---|---|---|
| Benefit Plan Contact | Form | Use For… |
| 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 | ||
| Tuition Grant Application | Tuition Grant Plan Application | Applying for tuition grant for dependent children for full-time studies |
| Dependent Expense Form | Document 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 | |
| Retirement Plans | ||
|---|---|---|
| Benefit Plan Contact | Form | Use For… |
| Empower/Prudential Support Staff Pension Plan |
Designation/Change of Beneficiary Form | Designation/Change of Beneficiary Form |
| Other Forms | ||
|---|---|---|
| Benefit Plan Contact | Form | Use For… |
| 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 | |