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Health Benefit Forms

PASSHE Health Plan Enrollment Change Form Document icon
PENNSYLVANIA STATE SYSTEM OF HIGHER EDUCATION New hires or newly eligible employees – form must be returned within 30 days All other qualifying life events – must be returned within 60 days of event (see 2nd page of form) TRANSACTION (TO BE COMPLETED BY HUMAN RESOURCES) ENROLLMENT ADD SPOUSE/DEPENDENTS -INDICATE REASON
Dependent Documentation Requirements Document icon
Documentation requirements to confirm dependent eligibility for the PASSHE Active Employee Health Care Program.
Spouse/Domestic Partner Health Care Attestation Form Document icon
For employees hired on/after July 1, 2013, spouse/domestic partner enrollment in the PASSHE plan requires primary coverage under the spouse’s/domestic partner’s employer group health plan.
Spouse/Domestic Partner Attestation Hired Prior to July 2013 Document icon
For employees hired prior to July 1, 2013, if your spouse/domestic partner is eligible for single coverage in their own employers health plan and that single coverage is available at no cost to the employee, then your spouse/domestic partner must enroll in that coverage as a condition for enrollment for secondary coverage in the PASSHE plan.
Domestic Partnership Certification Form Document icon
Form to certify same-sex domestic partnership for health benefits, leave benefits and tuition wavier benefits for faculty, managers and coaches
Domestic Partnership Termination Form Document icon
Form to terminate same-sex domestic partnership for faculty, managers and coaches
Health Insurance Claim Form Document icon
Health insurance claim form for Indemnity and PPO members
Prescription Drug Claim Form Document icon
Prescription Drug Claim Form for active employees and non-Medicare eligible AHCP enrollees.
Dental Claim Form for Nonparticipating Providers Document icon
Claim form for reimbursement of dental services provided by a nonparticipating provider for managers, coaches, OPEIU and SPFPA employees.  This form should not be used by faculty members.  For information on dental benefits for faculty members go to www.pafac.com.
Vision Claim form for Nonparticipating Providers Document icon
Claim form for reimbursement of vision services provided by a nonparticipating provider for managers, coaches, OPEIU and SPFPA employees.  This form should not be used by faculty members.  For information on faculty vision benefits go to www.pafac.com.
 
  • Human Resources Office
  • Sutton Hall, Room G8
    1011 South Drive
    Indiana, PA 15705
  • Phone: 724-357-2431
  • Fax: 724-357-2685
  • Office Hours
  • Monday through Friday
  • 8:00 a.m.–4:00 p.m.