Active Employee Medical Forms

FSA Direct Deposit Form

direct-deposit-form-03_2019.pdf 125.49 KB (Last Modified on April 5, 2019)

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FSA Dependent Care Account

Dependent Care reimbursement form.pdf 134.05 KB (Last Modified on April 5, 2019)

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FSA Certificate of Medical Necessity

2019 Certificate of Medical Necessity.pdf 185.24 KB (Last Modified on April 5, 2019)

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Life Insurance form - Metlife_Beneficiary

MetLife_Beneficiary.pdf 265.48 KB (Last Modified on November 1, 2017)

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2018 Student Certification Form

Student Certification form.pdf 24.89 KB (Last Modified on October 27, 2017)

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Return from Leave of Absence

Return from Leave Form.pdf 84.4 KB (Last Modified on October 13, 2017)

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FSA Reimbursement Request Form

Reimbursement Form .pdf 190.61 KB (Last Modified on April 5, 2019)

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ADA Parking Request

Parking Request.pdf 25 KB (Last Modified on October 13, 2017)

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HIPAA- Employee Authorization to Disclose

HIPAA.doc Employee Authorization to Disclose.pdf 24.17 KB (Last Modified on October 13, 2017)

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Attending Physician's Statement

Attending Physicians Statement-updated.pdf 62.78 KB (Last Modified on October 13, 2017)

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2019 Transfer Election Form

2019 Transfer Election Form.pdf 90.97 KB (Last Modified on October 29, 2018)

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2019 Enhanced-Over and Under 65 Enrollment form

2019 Excellus Enhanced Over and Under 65 enrollment form2019 .pdf 241.31 KB (Last Modified on October 29, 2018)

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2019 Traditional Basic BCBS Enrollment Form

2019 Excellus Basic only Enrollment form 5-11 .pdf 32.8 KB (Last Modified on October 29, 2018)

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2019 RCSD Enrollment -MVP Medicare Advantage Health Plan E

2019 MVP Medicare Advantage Group application.pdf 556.98 KB (Last Modified on October 29, 2018)

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2019 Medicare Bluechoice Group Advantage Application

2019 MBC Medicare Advantage Group Application.pdf 1,023.07 KB (Last Modified on October 29, 2018)

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The Rochester City School District does not discriminate on the basis of an individual's actual or perceived race, color, religion, creed, ethnicity, national origin, citizenship status, age, marital status, partnership status, disability, predisposing genetic characteristics, sexual orientation, gender (sex), military status, veteran status, domestic violence victim status or political affiliation, and additionally does not discriminate against students on the basis of weight, gender identity, gender expression, and religious practices or any other basis prohibited by New York State and/or federal non-discrimination laws in employment or its programs and activities. The District provides equal access to community and youth organizations.

Human Resources

Active Employee Medical Forms

FSA Direct Deposit Form

FSA Dependent Care Account

FSA Certificate of Medical Necessity

Life Insurance form - Metlife_Beneficiary

2018 Student Certification Form

Return from Leave of Absence

FSA Reimbursement Request Form

ADA Parking Request

HIPAA- Employee Authorization to Disclose

Attending Physician's Statement

Retiree Medical Forms

2019 Transfer Election Form

2019 Enhanced-Over and Under 65 Enrollment form

2019 Traditional Basic BCBS Enrollment Form

2019 RCSD Enrollment -MVP Medicare Advantage Health Plan E

2019 Medicare Bluechoice Group Advantage Application