Forms

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Insurance

Excellus BlueCross BlueShield Medical Claim Form

Link to online form
BlueCross BlueShield Global Core Claim Form

Link to online form
Excellus BlueCross BlueShield Authorization to Disclose Protected Health Information

Link to obtain form online
OptumRx Mail Order Form

For home delivery of ongoing medications for 90-day refills
Life Insurance Beneficiary Form

Life Insurance Beneficiary Form

Dental and Vision Insurance

Dental Claim Form
Vision Claim Form

For out-of-network services only

Flexible Spending Accounts (FSA)

Retirement Plans

Salary Reduction Agreement

403b Contributions
TIAA-CREF Designation of Beneficiary Form
Fidelity Designation of Beneficiary Form

Tuition Benefits

Employment

Payroll

Employment Authorization
W-4: Federal Employee's Withholding Allowance Certificate
IT-2104: NYS Employee's Withholding Allowance Certificate

All employees must complete this form in order to work in New York State
I-9: Employment Eligibility Verification Instructions
I-9: Employment Eligibility Verification
Student NY Wage Notice
New York State Wage Notice - Exempt Employees
New York State Wage Notice - Hourly Employees

Leave Bank

Performance Assessment

Worker's Compensation

Leave of Absence/Accommodations

Address/Personal Information Update

Complete the form to update your record for the HR and the directory.

Please note: Human Resources will update your address with benefits providers except TIAA. Please contact TIAA directly to update your address. You may update online under “My Profile” or by phone 800-842-2252.

Contact

Human Resources

Office Location

Philip Spencer House

Phone

315-859-4302