header.gif Aurora, photo credit Jan Curtis 2003 Closeup photo of man in office setting Closeup of flower, photo credit Nile Mueller Woman at Sitka campus, photo credit UAS Mt. McKinley, photo credit © Rex Melton, Alaska Division of Tourism Woman in UAS Environmental Science field class, photo credit UAS UAS HR UAF HR UAA HR UA Human Resources Home University of Alaska Home
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  A-Z Forms Index

  Employee Forms:
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HR Employee Forms

Health Forms:

Form Name Available Formats
(Icon Legend)
Form Descriptions
Blue Cross Health Care Claim Form Adobe PDF format file To submit health care claims to Blue Cross/Blue Shield.

Financially Interdependent Partners Explanation

Adobe PDF format file To explain and determine FIP eligibility.

Financially Interdependent Partners Statement

Adobe PDF format file To declare FIP eligibility.

FML Leave w/o Pay (FMLWOP), Sick Leave (LWOP) Form

Adobe PDF format file To arrange benefit payments while on LWOP.
FML Request Form Adobe PDF format file To request leave for a serious health condition (to be completed by employee).

FSA Claim For Medical And Dependent Care Form

Adobe PDF format file Computer enterable Adobe PDF format file To submit a claim for your flexible spending account.
FSA Direct Deposit For Medical And Dependent Care Form Adobe PDF format file To establish direct deposits of flexible spending account payments.
PharmaCare/Caremark Physician Prior Authorization Request Form (for prescriptions) Adobe PDF format file To be completed by patient's physician - to request authorization for prescription exceptions (i.e., medication usage past certain time period, specific medication brand, etc.).

PharmaCare/Caremark Prescription Drug Forms

Caremark Site Site contains reimbursement form for prescription drug claims; site also has other prescription related forms.
Student Enrollment Verification/Dependent Health Care Eligibility Adobe PDF format file Computer enterable Adobe PDF format file To verify student enrollment and/or to notify employees of dependent (child) health care coverage eligibility.
UA Choice Health Plan Enrollment Form - FY09 Open Enrollment

Adobe PDF format file

To enroll employee and dependents in UA health care plan for 7/1/08 through 6/30/09.
UA Choice Health Plan Enrollment Form - FY08

Adobe PDF format file

To enroll employee and dependents in UA health care plan for 7/1/07 through 6/30/08.
UA Choice Opt Out Form - FY09 Open Enrollment Adobe PDF format file To elect to opt out of UA health care coverage as of 7/1/08.
UA Choice Opt Out Form - FY08 Adobe PDF format file To elect to opt out of UA health care coverage and verify proof of other insurance coverage for 7/1/07-6/30/08.
UA Choice Supplemental Benefit Election Form - FY09 Open Enrollment Adobe PDF format file To add or delete employee selected benefits and/or deductions - i.e., FSA, AD&D, and other employee selected deductions such as accounts payable, parking, United Way, etc. (7/1/08-6/30/09).
UA Choice Supplemental Benefit Election Form - FY08 Adobe PDF format file Computer enterable Adobe PDF format file To add or delete employee selected benefits and/or deductions - i.e., FSA, AD&D, and other employee selected deductions such as accounts payable, parking, United Way, etc. (7/1/07-6/30/08).
VSP Out-of-Network Reimbursement Form Adobe PDF format file Effective 7/1/04: To submit a claim to VSP (vision vendor) for out-of-network provider reimbursements.

 

Please email syhr about any problems with this page   21-Apr-2008

  Photo credits: woman in field class and woman at Sitka campus photos courtesy of UAS; Mt. McKinley photo credit © Rex Melton,
Alaska Division of Tourism; flower photo credit Nile Mueller; aurora photo credit Jan Curtis 2003