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Forms and Information

COBRA ADMINISTRATION

  • 2623 RHS COBRA Administration*

DENTAL PLANS

  • 2389 RHS Group Enrollment Application Dental-Vision fillable
  • 2746 RHS Self-Insured Dental Plans (brochure)
  • 2870 RHS Dental Network
  • 2871 Participating Dentist Agreement fillable

FSAs

  • 2698 Flexible Spending Account (FSA) Eligible Expenses
  • 2736 Run Out Grace Period Roll Over Document (download)
  • 2747 RHS FSA Brochure
  • 2753 Employee FSA Enrollment Form & Agreement*
  • 2754 FSA/HRA Reimbursement Request Form
  • 2755 Adoption Agreement Section 125 (FSA-POP)
  • 2782 FSA Frequently Asked Questions

HRAs

  • 2296 Enrollment Application for Group Coverage
  • 2299 HRA Reimbursement Request Form
  • 2805 RHS HRA Process

POP PLANS

  • 2297 Salary Redirection Agreement (POP-HSA)

OTHER FORMS

  • 2757 Employer Application (fillable PDF)*
  • 2757 Employer Application (non-fillable PDF)*

LOGIN PROCEDURES

  • 2791 Employee/Employer Login Procedure for RHS Secondary Card
  • 2791 Employee Login Procedure for RHS Benefits Card

Section

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