Forms and Documents for Staff

Payroll Forms 

• W-4 Form – Use to change your tax withholding election.
• IT-204 Form – Use to change your state tax withholding election (if different from federal).
• Direct Deposit Form

Retirement Forms

• TRS Application – Membership required for all full-time teachers and teaching assistants. Part-time teachers and substitutes have the option to join.
• Other TRS Forms – list to other TRS forms you may need
• NYSLRS Application – NYS Employees’ Retirement System – membership required for full-time, 12-month employees. Other non-instructional employees have the option to join.
• Other NYSLRS Forms – list of other NYSCRS forms you may need

Medical

• Highmark/BlueShield Enrollment/Change Form – This form must be completed to enroll/change/drop the district’s health insurance coverage.
• Highmark BS 815 PPO Plan Benefit Summary– quick overview of benefits for active employees covered under the PPO 815 plan

Prescription

• Express Scripts Mail-Order Form – This is the form you will need to take advantage of Medco’s mail-order prescription program.
• CANARX Member Package– The district’s health plan includes a mail order program to obtain certain brand-name medications at a zero cost co-pay. Click the link for more information.
• CANARX list of medications–This is the list of prescription drugs covered with a $0 co-pay under CANARX (effective January 2023).

Health Reimbursement Forms

• Dental reimbursement form – To seek reimbursement for covered dental expenses
• Dental Claim Form (2023)
• Dental Plan Information (2023-24)
• HRA reimbursement form – Health Reimbursement Agreement/Medical Expense Recovery form for covered expenses
• Preferred PG Group Flexible Spending Plan Reimbursement Voucher – Unreimbursed medical expenses and dependent/child care expenses

Other Forms

• Blue Vision Benefits Summary – Overview of vision benefits and discounts
• Blue Vision Flyer – Informative flyer about the new Blue View Vision program
• Empire Vision Enrollment Form
• Omni 403b Enrollment Information 
• Omni Universal Notice
  For more information: https://www.omni403b.com/