CONTENTS
| 2013 Medical and Dental Insurance Enrollment/Changes | Faculty and staff: To enroll or make changes to your health insurance coverage during Open Enrollment (November 1–30) with changes going into effect on January 1, 2013:
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| Medical Plan Claim Forms | Medical claim forms are available at the provider's website: |
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| PEBB Employee Enrollment Guides | Summary of all Public Employee Benefits Board (PEBB) benefits including medical, dental, long term disability, life, etc. |
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| Medical Plans - Summaries of Benefits and Coverage (SBC) | For an easier, more standardized comparison tool of medical plan benefits, terms, and conditions, see the PEBB Summary of Benefits and Coverage. The SBC is also available upon request in Spanish, Tagalog, Chinese, and Navajo. |
| Medical Plans - Benefits Booklets | Find the Benefits Booklet (Certificate of Coverage) at your medical plan's website listed below: |
| Dental Plans |
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| 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 | Return this 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 Table for 2013 (PDF) |
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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
