Forms
You can access the most commonly used benefits forms on this page. Don’t see a form you need? Please reach out to a member of PNW’s benefits team.
- Anthem Medical Claim Form
- Delta Dental Claim Form
- Vision Service Plan (VSP) Out-of-Network Claim Form
- Anthem Continuation of Insurance for Disabled Children Form
- CVS Caremark Prescription Claim Form
- CVS Caremark Prescription Mail Order Form
- Tobacco User Certification Form (For those who become 12-months tobacco-free midyear) (Please list Rhonda Greear at hr@purdue.edu as the individual that should receive the notification)
- Working Spouse Additional Premium Waiver Form
- HSABank
- PayFlex (for 2018 and prior accounts)
- (FSA/HRA) PayFlex Reimbursement Account Claim Form
- (FSA/HRA) PayFlex Reimbursement Claim Form Instructions
- ·(FSA/HRA) PayFlex Letter of Medical Necessity Form
- ·(All accounts) PayFlex Direct Deposit Form (HSA) PayFlex Account Closure Form
- (HSA) PayFlex Beneficiary Designation Form
- (HSA) PayFlex Return of Excess Contributions
- (HSA) PayFlex Trustee Transfer Form
- Family and Medical Leave Act (FMLA) Forms
- Please contact human resources at hr@pnw.edu for the appropriate forms and process for requesting FMLA leave.
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