CONTENTS
| Medical and Dental Insurance Enrollment/Changes | Download the 2012 Enrollment/Change Form (PDF). Faculty and staff: Submit this form to enroll or make changes to your health insurance coverage during 2012.
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| Medical Plan Claim Forms | Medical claim forms are available at the provider's website: |
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| Dental Plans |
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| Medical Plan Certificates of Coverage Booklets | The remaining 2012 benefits booklets will be posted as soon as they are available. If you have questions about a certificate of coverage, or you would like to receive a copy, contact the plan. |
| PEBB Employee Enrollment Guide | Summary of all Public Employee Benefits Board (PEBB) benefits including medical, dental, long term disability, life, etc. |
| Address Updates | |
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| Dependents with Disabilities | Use this form to request certification of a disabled dependent. |
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| Extended (legal) Dependents | Use this form to request certification of a dependent child who is not yours through birth, adoption, marriage, or a qualified domestic partnership. |
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| COBRA Continuation or Extension of Coverage | Use this form to continue medical/dental coverage after loss of eligibility. |
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| Electronic Debit Service | Use this form to self-pay your monthly premium while enrolled in COBRA. |
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| Leave Without Pay (LWOP) Continuation of Coverage Election | Faculty and staff: Use this form to continue medical, dental, life, and LTD coverage while on leave without pay. |
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| Electronic Debit Service | Use this form to self-pay your monthly premium while enrolled in COBRA. |
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| Health Savings Account (HSA) Beneficiary Designation Form | Download the HSA Beneficiary Designation form (PDF). Return the form directly to HealthEquity. |
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| HSA Payroll Deduction Authorization Form | Download the 2012 Payroll Authorization form (PDF). Return the form to the UW Benefits Office. |
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| HSA Forms, Publications, Tutorials | HealthEquity (HE) is the trustee for Public Employee Benefits Board (PEBB) members' Health Savings Accounts. Get publications and tutorials. |
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Qualified & Non-Qualified Medical Expenses (Gastos Médicos Calificados Y No Calificados) |
Download this publication in English and Español. (PDF format) |
| Complete HSA Guidebook | Download the HSA Guidebook. (large download in PDF format) |
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| FSA Forms and Publications | To download a FSA form or document, see ASIFlex's web site. Mail FSA forms directly to: ASIFlex, PO Box 6044, Columbia, MO 65205-6044 or fax to 1-866-381-9682. |
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| Authorization of Release of Information | To authorize use or disclosure of personal health information for employee or their dependents. |
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| Tax Issues Related to PEBB Non-Tax Qualified Dependent Insurance | Download the rate tables: |
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Contact us if you cannot find a form or publication on this page or through one of the links shown at right. To report a web problems, contact benefits@uw.edu.
FORMS & PUBLICATIONS
