Benefits Forms

When submitting applications for Enrollment please follow the  guidelines below:

Medical Application

This SDP Health Application and Attestation Form is for all SDP provided medical and health plans. You may need to contact your union for prescription, dental and vision benefits. Complete all sections in entirety. Visit the Independence Blue Cross site for up to date information on all Independence Blue Cross plans.

Please refer to General Documentation Required section for a list of documents that may need to accompany your completed application. The completed application and documentation, if required, can be faxed in to the Benefits Office at (215) 400-4631 or emailed to benefits@philasd.org. Please call (215) 400-4630 to confirm receipt if submitting by fax.

• SDP Health Application and Attestation Form
• Request to Remove a Spouse or Dependent
• Personal Choice Out of Network Claim Form
• Exchange Notice

Vision

• PFT & Local 634 Members Vision coverage is provided by your union. If you are enrolled in Keystone medical coverage, you have additional vision coverage through Davis Vision hmo-benefit
• CASA, SPAP and Non-Represented Employees: Vision Rider Program Overview
• Non Participating Provider Reimbursement Form

Dental –  CASA, SPAP and Non-Represented Employees ONLY

• Cigna Dental Oral Health Integration Program® Registration Form

Prescription Drugs –  CASA, SPAP and Non-Represented Employees ONLY:

• Prescription Summary
• Future Scripts Mail Service Order Form
• Prescription Reimbursement Claim Form

Self- Injectable Prescription Drugs for PFT employees are covered through the PFT Health and Welfare prescription plan as of October 2021. 

Disabled Dependent Child

When a dependent covered through a parent’s health plan turns 26 years old, they are terminated from the plan and must seek separate coverage.

If a parent or parents of a disabled dependent would like to keep the dependent on their plan, they must complete and submit the appropriate application to Independence Blue Cross (Independence).

It is the member’s responsibility to ensure this application is completed and received by Independence in a timely manner to secure continued coverage.

Disabled Dependent Application

Life Insurance Beneficiary Forms

• Life Conversion Form
• Hartford Change of Beneficiary for Active Employees
• Retiree Designation of Beneficiary Form

Flexible Spending Account changes 

No forms to complete! for changes contact the Employee Benefits Center at 1-800-307-0230 between 8:30AM – 5:30PM EST Monday through Friday for all questions.

Flu and COVID Vaccine Reimbursement Form.

Immunizations, including flu shots and COVID-19 vaccines are not covered under the prescription plans for PFT represented and Unite Here Local 634 employees.  These employees would need to pay out of pocket and submit the below form for reimbursement through the medical plan.

• Flu Reimbursement Form from Independence
• HMO COVID-19 vaccine Reimbursement form
• PPO COVID-19 vaccine Reimbursement form

Important: CVS and Rite Aid are in network retail pharmacy with Independence Blue Cross for those employees with prescription coverage through Independence Blue Cross.

Walgreens is considered out of network. Find an in network retail pharmacy at https://www.ibx.com/get-care/find-doctors-and-healthcare-providers/find-a-pharmacy.

 

403(b) & 457(b)

• 403b Salary Reduction Agreement
• 457b Salary Reduction Agreement

Wage Continuation (Salary Continuation)

PFT, CASA, Non-Represented, Local 634, District 1201/32 BJ and SPAP employees can only apply for Wage Continuation coverage within 30 days of date of hire or during the annual Open Enrollment period.  Coverage can only be cancelled during the annual Open Enrollment period. Forms are only available May 1 through May 31. Forms are also available on the Open Enrollment page

Wage Con Enrollment Form

Wage Continuation Cancellation Form

First year PFT employees can contact benefits@philasd.org for enrollment in their first year.

Name Change/Demographic Change Request

• Demographic Update or Correct Form to update or correct name, gender, pre-fix , or correct date of birth.
• Marital-Status-Change-Request Use this form to update your voluntary marital status, not your tax filing status. Contact the Payroll Department, payrollhelp@philasd.org for tax filing status.

Employees must contact Payroll, payrollhelp@philasd.org or 215-400-4490 to request an address change or a change in tax withholding status.

COBRA /RETIREE Coverage forms

An Automatic Payment (Ach) Request

How do I change or correct my name on my Social Security number card?

If you legally change your name because of marriage, divorce, court order or any other reason, you must tell Social Security so you can get a corrected card. You cannot apply for a card online. There is no charge for a Social Security card. To get a corrected Social Security card, you will need to:

• Show the required documents. You will need proof of your identity.  See Learn What Documents You Need for more information. Under the heading, “Type of Card,” select “Corrected” for a list of the documents you need;
• Fill out and print an Application for a Social Security Card; and
• Mail your application and documents to your local Social Security office.

For complete instructions, please go to  Social Security Number and Card.
For more information, read the pamphlet, Your Social Security Number and Card.