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Benefit forms

Health Insurance

NYSOH Marketplace Notice and Memo

2021 ACA Declination Form

Excellus PPOH vs Classic Blue Comparison

Classic Blue_PPO-H Benefit Booklet

Excellus Classic Blue Member Contract

Excellus PPO-H Member Contract

Excellus Classic Blue SBC

Excellus BCBS PPO SBC

Excellus Medical Claim Form

Excellus HIPAA Authorization Form

Excellus Enrollment_Change Form

Excellus International Claim Form

Excellus International Travel Blue Card Information

MDLive Telemedicine

MDLive Telemedicine FAQ's

Dental Forms

Excellus Enrollment Form ***(BTA ONLY)***

Excellus Dependent Certification Form ***(BTA ONLY)***

Excellus Dental Plan Booklet ***(BTA ONLY)***

The Standard Detailed Benefit Summary

The Standard Highlight Sheet

The Standard Dental Claim Form

The Standard Dental Online Benefits Flyer

The Standard Dental Privacy Notice

The Standard Dental Enrollment Form

The Standard Vision Claim Form

Vision

Davis Vision & VSP Benefit Summaries

VSP-Davis Vision 21 Pay Benefit Summary

VSP-Davis Vision 26 Pay Benefit Summary

Davis Vision Network Providers

Davis Vision Claim Form

VSP Network Providers

Flex Spending

FSA Enrollment Form

FSA Medical Reimbursement Form

FSA Dependent Care Reimbursement Form

FSA Mobile App Information

FSA Account Access Instructions

FSA Qualifying Expenses

FSA Medical Necessity Form

IRS Publication 502 - Medical and Dental Expenses

IRS Publication 969 - Dependent Eligibility

Retirement

403(b) Enrollment Form

403(b) 2018 list of service providers

ERS Tier 6 booklet

TRS SS verification

TRS prior service claim

TRS name and address chg form

TRS beneficiary form

Supplemental service ERS

Military service credit

ERS Tier 5 plan booklet

2017-18 ERS Loan Form

ERS change of name

ERS Change of address

ERS beneficiary form

HR - Retirement

403(b) Salary Reduction Agreement

403(b) UA Notice

2017-18 ERS Loan Form

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Broome-Tioga BOCES 435 Glenwood Road Binghamton, NY 13905 Phone: (607) 763-3300

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