HEALTH AND BENEFITS FORMS

Biometric Health Screen Results from your personal Health Care Provider - Required Forms:
Verification of Biometric Health Screen Completion Form
Biometric Screening Results Form
WSP - Consent to Participate in Biometric Screening and Authorization for Release of Information Form
Wright State Physicians - Notice of Privacy Practices

Domestic Partner Benefits Forms
Domestic Partner Certification Checklist
Domestic Partner Health Enrollment Form 
Affidavit of Domestic Partnership   
Certification of Tax-Qualified Dependents
Termination of Domestic Partnership

Health Enrollment and Claim Forms
19-26 Adult Child Certification Form    *only needed if making changes
26-28 Adult Child Certification Form    *required
26-28 Adult Child Affidavit Form    *required
26-28 Adult Child Health Enrollment Form *required
Anthem Medical (out of network) Claim Form
Dental Claim Form  
Flexible Spending Agreement Form
Flexible Spending Account Claim Form
Family and Medical Leave Application
Health Insurance Enrollment/Change Form Instructions
Health Insurance Enrollment/Change Form
Health Insurance Enrollment/Change Form for Bargaining Unit Tenure Track Faculty only
Health Savings Reduction Form
HSA Employee Contribution Form
Life Insurance Beneficiary Change Form
Medicare Secondary Payer Act Status Form
Orthodontic Claim Form
Prescription Claim Form
Vision (out of network) Claim Form
WellPoint NextRx Prescription Drug Claim Form (HDHP Plan)

Retirement Forms
Retirement Plan Election Form
Alternative Retirement Plan (ARP) Vendor Change Form

TAX FORMS
Federal Tax Form
State of Ohio Tax Form