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  • About
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Active Employee Medical Forms

  • Dependent-Adopted Child Form

    Dependent-Adopted Child Form

    Dependent-Adopted Child Form.pdf 130.68 KB (Last Modified on November 25, 2019)
    Comments (-1)
  • FSA Direct Deposit Form

    FSA Direct Deposit Form

    direct-deposit-form-03_2019.pdf 125.49 KB (Last Modified on April 5, 2019)
    Comments (-1)
  • FSA Dependent Care Account

    FSA Dependent Care Account

    Dependent Care reimbursement form.pdf 134.05 KB (Last Modified on April 5, 2019)
    Comments (-1)
  • FSA Certificate of Medical Necessity

    FSA Certificate of Medical Necessity

    2019 Certificate of Medical Necessity.pdf 185.24 KB (Last Modified on April 5, 2019)
    Comments (-1)
  • Life Insurance form - Metlife_Beneficiary

    Life Insurance form - Metlife_Beneficiary

    MetLife_Beneficiary.pdf 265.48 KB (Last Modified on November 1, 2017)
    Comments (-1)
  • Student Certification Form

    Student Certification Form

    Dependent Student Certification Form 2020-2021.pdf 299.13 KB (Last Modified on October 2, 2020)
    Comments (-1)
  • Return from Leave of Absence

    Return from Leave of Absence

    Return from Leave Form.pdf 84.4 KB (Last Modified on October 13, 2017)
    Comments (-1)
  •  FSA Reimbursement Request Form

    FSA Reimbursement Request Form

    Reimbursement Form .pdf 190.61 KB (Last Modified on April 5, 2019)
    Comments (-1)
  • ADA Parking Request

    ADA Parking Request

    Parking Request.pdf 25 KB (Last Modified on October 13, 2017)
    Comments (-1)
  • HIPAA- Employee Authorization to Disclose

    HIPAA- Employee Authorization to Disclose

    HIPAA.doc Employee Authorization to Disclose.pdf 24.17 KB (Last Modified on October 13, 2017)
    Comments (-1)
more
 

Retiree Medical Forms

  • 2022 Excellus Medicare Group Application Not SEG

    2022 Excellus Medicare Group Application Not SEG

    2022 Excellus Roch Medicare GroupApplication NOT SEG.pdf 1.06 MB (Last Modified on January 26, 2022)
    Comments (-1)
  • 2022 Excellus Medicare Group Application

    2022 Excellus Medicare Group Application

    2022 Excellus Roch Medicare GroupApplication updated.pdf 1.06 MB (Last Modified on November 5, 2021)
    Comments (-1)
  • 2020 Directory West Region

    2020 Directory West Region

    2020 Medicare Directory West Region.pdf 2.19 MB (Last Modified on October 30, 2020)
    Comments (-1)
  • MVP Health Care 2022 Medicare Part D Formulary

    MVP Health Care 2022 Medicare Part D Formulary

    2022 MVP Formulary.pdf 2.13 MB (Last Modified on November 5, 2021)
    Comments (-1)
  • 2022 Transfer Election Form

    2022 Transfer Election Form

    Transfer_Election_Form.pdf 109.25 KB (Last Modified on January 26, 2022)
    Comments (-1)
  • 2021 Enhanced-Over and Under 65 Enrollment form

    2021 Enhanced-Over and Under 65 Enrollment form

    2021 Enhanced-Over and under 65.pdf 240.85 KB (Last Modified on October 30, 2020)
    Comments (-1)
  • 2021 Traditional Basic BCBS Enrollment Form

    2021 Traditional Basic BCBS Enrollment Form

    2021 Basic only appl 5-11.pdf 32.8 KB (Last Modified on October 30, 2020)
    Comments (-1)
  • 2022 RCSD Enrollment -MVP Medicare Advantage Health Plan E

    2022 RCSD Enrollment -MVP Medicare Advantage Health Plan E

    2022 MVP Application.pdf 523.63 KB (Last Modified on November 1, 2021)
    Comments (-1)

Address CO Hours: M-F, 8am to 5pm
131 W. Broad Street, Rochester , NY 14614

Phone 585-262-8100

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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. NYS CR Part #154 requires the District to provide communications to ELL families in the home language that they best understand. In order to request interpretation or translation services, employees may visit www.rcsdk12.org/translationservices. For emergencies or immediate communication needs, please use the Language Line at 1-866-874-3972. School secretaries in each school or program can provide the access code for this service.
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. NYS CR Part #154 requires the District to provide communications to ELL families in the home language that they best understand. In order to request interpretation or translation services, employees may visit www.rcsdk12.org/translationservices. For emergencies or immediate communication needs, please use the Language Line at 1-866-874-3972. School secretaries in each school or program can provide the access code for this service.
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