Forms

Dental

• JJS Claim Form

Excess Major Medical (EMM)

• Vision Claim Form
• In-Hospital Claim Form
• Excess Major Medical (EMM) Claim Form
• Request A Benefits Meeting

Vision

• JJS Claim Form

Flexible Spending (Section 125)

• Dependent Care Reimbursement
• Healthcare Reimbursement
• Orthodontic Worksheet

Eligibility

• Student Status Verification Form
• Change of Beneficiary Form
• Change of Name Form
• Change of Address Form

HRA

• Reimbursment Form

EASO

• Claim Form

 

EEHP Medical ACH Enrollment Form

• Automatic Premium Deduction Authorization Form