Health Benefit Forms

PASSHE Health Plan Enrollment Change Form: Form to enroll in or make changes to health and prescription drug plan.
Dependent Documentation Requirements: Documentation requirements to confirm dependent eligibility for the PASSHE Active Employee Health Care Program.
PASSHE Adult Child Attestation Form: Form needed to add adult children (ages 19-26) to PASSHE health care coverage.
Domestic Partnership Certification Form: 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: Form to terminate same-sex domestic partnership for faculty, managers and coaches

Health Insurance Claim Form: Health insurance claim form for Indemnity and PPO members
Prescription Drug Claim Form: Prescription Drug Claim Form for active employees and non-Medicare eligible AHCP enrollees.
Dental Claim Form for Nonparticipating Providers: 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: 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.

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