Human Resources / Forms

Human Resources Staff Forms

Benefits	Personnel
Flexible Benefit Plan: List of Qualifying Events	Licensed Personnel Recommendation (Print on yellow paper)
State Health Plan Comparison of Employee Contribution (2011-2012)	Classified Recommendation Form (Print on blue paper)
Benefit Comparison Plan Choice at a Glance	Telephone Reference Call
Health Insurance Claim (State Plan) PPO Plan or Indemnity Plan	Health Examination Certificate
Prescription Claim	Termination of Employment (Print on Yellow Paper)
Authorization Request Form - HIPAA - PPO Plan or Indemnity Plan	Employee Transfer Request (Print on green paper)
HIPAA Privacy Rule Information	Employee Address/Phone Change
Voluntary Shared Leave Application(Print on green paper)	Licensed Vacancy Permit to Advertise a Vacancy
Voluntary Shared Leave Donation (Print on blue paper)	Request For Forms
Leave Request Packet
Workers' Compensation / OSHA	National Board Prog. Facilitator Contact Log
First Report of Injury	NBCT Renewal Reimbursement Request
Incident Investigation Form
CorVel Physician Pharmacy Report
Travel Reimbursement Form	Contract
Workers' Compensation Frequently Asked Questions	Exit Interview
	Pre-Employment Worksheet
	Licensed Resignation
	Vacancy Permit