Benefits Forms

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
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 BCBS Disability Qualification Questionnaire Verifying your disabled dependent’s eligibility for coverage under the CareFirst BCBS medical plan
EHP Medical/Vision Claim Form Submitting medical and vision claims
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…
The Hartford (prior to 01/01/2021)

 

Long Term Disability Claim Form Applying for long term disability
Certificate of Previous LTD Coverage Documenting eligibility for waiver of one-year waiting period
Long Term Disability Conversion Form Retaining your LTD coverage if you leave JHU

 

Tuition Assistance
Benefit Plan Contact Form Use For…
Tuition Remission Applications Faculty and Staff Tuition Remission Plan Application Applying for tuition remission for part-time studies and professional development courses
Spouse/Domestic Partner Tuition Remission Plan Application
Dependent Child Tuition Remission Plan Application
Tuition Remission for Continuing Education Courses Outside of JHU Application
Tuition Reimbursement Applications Tuition Reimbursement Plan Application for Faculty and Staff Applying for tuition reimbursement for part-time undergraduate studies outside JHU

Faculty/Staff who live and work outside the Baltimore/Washington metropolitan area may also submit tuition reimbursement for part-time graduate studies outside of JHU

Tuition Reimbursement Plan Application for Bargaining Unit Members
Tuition Grant Application Tuition Grant Plan Application (updated form to be available in May) 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…
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 Marriage/ Domestic Partnership Verifying divorce or termination of marriage ordomestic partner relationship