Personnel / Forms

Dental Claim Form
by

DentalClaimForm.pdf, 180.57 KB (Last Modified on April 30, 2013 )

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Health Insurance (Empire) Claim Form
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EmpireHealthInsuranceClaimForm.pdf, 28.74 KB (Last Modified on January 31, 2012 )

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Health Insurance (Empire) Claim Form -- Physician Form
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EmpireHealthInsuranceDoctorClaimForm.pdf, 48.87 KB (Last Modified on April 4, 2012 )

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Health Insurance Opt-Out Provision Form
by Ann Mulligan
This form is for Central Administrators, Managerial, Building Administrators, Teachers, Teacher Assistants, Chairpeople, and Nurses.

OptOutInsuranceForm.pdf, 7.02 KB (Last Modified on March 14, 2012 )

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Health Insurance Opt-Out Provision Form for Clerical Staff
by Ann Mulligan
This form is for Clerical Staff.

OptOutInsuranceClericalForm.pdf, 7.03 KB (Last Modified on March 14, 2012 )

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Health Insurance Opt-Out Provision Form for Custodial Staff
by Ann Mulligan
This form is for Custodians and Head Custodians.

HealthInsuranceOptOutProvisionForm.pdf, 7.02 KB (Last Modified on January 31, 2012 )

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PA Health Insurance Transaction Form
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PAHEALTHINSURANCETRANSACTIONFORM.pdf, 30.43 KB (Last Modified on January 31, 2012 )

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Request for Leave Time
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If you intend to obtain this cancer screening during your normal work hours, you must complete this form and a Consolidated Leave Report, at least two (2) weeks prior to your doctor’s appointment and submit it to your building principal for his/her signature.

RequestForLeaveTime.pdf, 7.35 KB (Last Modified on September 11, 2012 )

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Vision Statement of Claim
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Vision Claim Form.pdf, 194.25 KB (Last Modified on April 30, 2013 )

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Personnel

Dental Claim Form

Health Insurance (Empire) Claim Form

Health Insurance (Empire) Claim Form -- Physician Form

Health Insurance Opt-Out Provision Form

Health Insurance Opt-Out Provision Form for Clerical Staff

Health Insurance Opt-Out Provision Form for Custodial Staff

PA Health Insurance Transaction Form

Request for Leave Time

Vision Statement of Claim