!nfonet - For University of Pittsburgh Medical Center staff
!nfonet - For University of Pittsburgh Medical Center staff

Forms

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Benefits

If you are searching for a benefits form that is not listed below, contact your Human Resources department or call UPMC DirectLink at 1-800-994-2752 and select option 3.


Benefits Enrollment

Go to the Benefits website >


Brochures

  • Benefits Overview 2011 (PDF)
    • Benefits described in this brochure give a general overview of the benefits available through UPMC. They represent the standard benefits for most UPMC staff members, but may not be applicable to all staff.
    • Some business units have unique benefit programs. Additionally, certaiin job classifications may affect benefit eligibility. Physicians and members of collective bargaining units should refer to the terms of their contracts for information regarding their eligibility for UPMC benefits.
    • Specific benefit related questions should be directed to the UPMC Employee Service Center at 1-800-994-2752, option 3.
  • Changes in Status (PDF)
  • My HUB/DirectLink (PDF)
  • Voluntary Benefits (PDF)


Medical Coverage

  • Dental Claim UPMC Dental Advantage (PDF)

  • Dental Claim United Concordia (PDF)
    The dental claim form is available from the Client's Corner section of the United Concordia website.
     
  • Flexible Spending Account Dependent Care Claim (PDF)
    Use this form to submit claims and receive reimbursements from your dependent care FSA.
     
  • Flexible Spending Account Health Care Claim (PDF)
    Use this form to submit claims and receive reimbursements from your health care FSA.
     
  • Flexible Spending Account Substantiation Form - Submitting receipts for substantiation of your FSA debit card expenses is only necessary when requested by the FSA administrator. To make this process as simple as possible, identify a current e-mail address in your online MyFlex Advantage account. When substantiation is needed, you will be sent an e-mail or a letter with instructions. Already received a substantiation request but you misplaced your letter? Contact UPMC Health Plan to request a copy 1-888-876-2756 or send an e-mail to myflex@upmc.edu.
  • Mail Order Prescriptions
    For more information, visit the UPMC Health Plan website.


Miscellaneous

  • Adoption Assistance Reimbursement (PDF)
    Submit this form to the Employee Service Center along with requested documentation to verify expenses incurred during the adoption process.
     
  • Commuter Parking Account Reimbursement Request (PDF)
    This form should be submitted along with documentation showing your work-related parking expenses incurred at a non-UPMC parking facility.

  • Commuter Parking Enrollment Form (PDF)
  • Domestic Partnership Affidavit (PDF)
    This document is used to initiate benefits for your domestic partner and the children of your domestic partner. After completing this affidavit and having it notarized, submit the affidavit along with the indicated documentation to the UPMC Employee Service Center.
     
  • Domestic Partnership Termination (PDF)
    If your domestice partnership has ended, use this document to terminate benefits coverage for the listed domestic partner and the children of that partner.
     
  • Enrollment Documentation (PDF)
    Submit this form along with documentation that supports a dependent's or spouse's eligibility to be covered under or removed from your benefit plans. (Ex. divorce decree or legal guardianship court order)
     
  • PTO Sell
    Eligible staff may sell accrued paid time off back to UPMC at any time during the year. To sell back your PTO, login to My HUB. Then, use the My Payroll link to access the PTO Sell Request.


Annual Reports for Pension and Health and Welfare Programs


Tuition Assistance

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