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Benefit Forms & Information
Tuition Reimbursement
Leave of Absence
Healthcare Provider Forms
NOTE: It is important that the department personnel officer is immediately made aware of any leave in order to comply with Federal notice regulations under the Family Medical Leave Act.
- Family Medical Leave Act
- Employee - Certification of Health Care Provider
- Family Member - Certification of Health Care Provider
- Military Family - Certification of Qualifying Exigenc
- Injured Service Member
- Leave of Absence Request
- Return From Leave Notice
- Approved Medical Facilities
- Injury Report
- Eligibity and Rights #26 Responsibilities
- Authorization to Release Health Care Information
Benefits
- Dependent / Income Verification - IRS Form 4506T
- Enrollment Change of Status Form
- Flexible Spending Reimbursement Claim Form for Medical Expenses
- Flexible Spending Reimbursement Claim Form Dependent Care
- Flexible Spending Reimbursement Claim Form for Parking/Commuter Expenses
- Flexible Spending Account Plan Change in Status Form
- Optical Reimbursement Form
- Health and Welfare Plan
- Health and Welfare Plan Amendment
- LTD Plan
- Women's Newborns & Mothers Health Notice
- COBRA Healthcare Continuation Notice
- Healthcare Opt Out Form
- Medicare Prescription Drug Credible Coverage Notice
- Womans' Health and Cancer Rights Act
- ID Theft Program Deduction Authorization Form
- HSA Deduction Authorization Form
- Notice of Health Care Exchange
- HIPAA Notice of Privacy Practices
- Mental Health Parity Notice of Exemption
- 3rdCC HSA One-Time Bonus Payment
General Health Benefit Plan Information
Benefit Forms
- Open Enrollment Change Forms:
- Actives Employees Visit Enrollment Portal: CURRENTLY CLOSED
- Retiree - CURRENTLY CLOSED
- Enrollment / Change of Status Form
- IRS Form 4506T (use for dependent and/or income verification)
- Health Care Opt Out Form
- Medicare Advantage Enrollment Form (EXEC/LEG)
- Medicare Advantage Enrollment Form(LEG)
- Medicare Advantage Enrollment Form(ALL OTHER)
- FSA Enrollment Forms:
Medical / Prescription Drug, Dental & Vision
- See Benefit Comparisons section above for medical, dental, vision and hearing information specific tovarious collective bargaining agreements / benefit plans / retirees
- Medical Plan Options Information
- BCBSM / BCN Custom Select Formulary Quick Guide
- BCBSM Preventative Drug List (applicable to BCBSM Simply Blue HDHP PPO plan participants only)
- DENCAP Retiree FAQ
- DENCAP Retiree Advantage Schedule
Flexible Spending Accounts (FSA), Health Savings Accounts (HSA), Health Reimbursement Accounts (HRA) & Retiree Medical Savings Accounts (RMSA)
- Plan Documents & Account Access
- Frequently Asked Questions (FAQs)
- Qualified Medical Expenses
- Tax Benefit Example
- Important 2018 Family Contribution HSA Limit Change
- Update on 2018 HSA Family Contribution Limit Change
- FSA Enrollment Forms:
Life Insurance
- Basic Group Life Insurance: Basic (employer-paid) life benefits are determined by the terms and provisions of applicable collective bargaining agreements and benefit plans.
- Supplemental Group Life Information
- Beneficiary Designation Information
- Beneficiary Designation Form
- Supplemental Group Life InsuranceElection & Beneficiary Designation Form
Other Value-Added Benefits and Voluntary / Supplemental Benefits
- Employee Assistance Program (EAP) - FREE & CONFIDENTIAL counseling services available 24/7/365 to employees and family members through HMSA
- Value-Added Benefits for Active Employees
- Voluntary Benefit Plan Options:
IMPORTANT Health Plan / Employee Rights Notices
- Notice of Health Care Exchange Options
- Rights Under COBRA
- Medicare Prescription Drug Program Notice of Creditable Coverage
- Mental Health Parity & Addiction Equity Exemption Notice
- Other Federal Health Reform Notices
- HIPAA Notice of Privacy Practices
- Women's Health & Cancer Rights Notice
- Newborns & Mothers Health Protection Act Notice
- Children's Health Insurance Program Notice
Frequently-Used Links
Wayne County Retiree Stipend Program
- Program Summary
- McDonald et al v. Wayne County Settlement Agreement
- Pre-Medicare Stipend Information Verification Form
- Group Benefit Information: AmWINS Website or call 877-847-9906 M-F 8am - 8pm EST
- Medicare-Eligible Stipend Account Information: Genesis Employee Benefits Website or call 866-678-8322
- Call the Benefits Division: 313-224-5157 or eMail: benefits@waynecounty.com
