Forms

These forms are available in PDF (Portable Document Format). They are best viewed with the latest (free) version of Adobe Acrobat Reader.

Benefits Plan

Life Event Change (Retirees, Survivors & Inactive Plan Members)

Seminary Student Benefits Plan Membership Application

Transitional Participation Coverage Enrollment: Minister's Choice

Transitional Participation Coverage Enrollment: Pastor's Participation

Validated Ministry Registration

Address and Contact Information Change Form

Post-Retirement Service Registration

Death benefits

Death Benefits Claim

Student's Application for Education Benefit

Beneficiary Designation Form

Supplemental Death Benefits Application

Supplemental Death Benefits Health Statement (Member)

Supplemental Death Benefits Health Statement (Spouse)

Electronic funds transfer

Authorization for Direct Deposit

Giving opportunities

Assistance Program Gift and Donation Form

Grant applications

Clergy Wellness Support Application

Emergency Assistance Application

Employee Vocation Program Application

Income/Housing Supplement Application

Minister Debt Relief Grant Application

Minister Educational Debt Assistance Application

Medical Record Attestation Form

Organizing Pastors/Evangelists Grant Enrollment Application

Organizing Pastor/Evangelists Grant Renewal Application

Retiree Medical Grant Application

Sabbath Sabbatical Support Grant Program Application

Transition-to-College Assistance Application

HIPAA/privacy

Designation of Personal Representative

Authorization to Release Medical Plan Information

Authorization for Use or Disclosure of Protected Health Information

Member or Dependent Authorization to Use and Disclose Personal Employment and Financial Information

Benefits Plan of the Presbyterian Church (U.S.A.) Medical Plans - Request for Accounting of Disclosures

Benefits Plan of the Presbyterian Church (U.S.A.) Medical Plans - Request for Access to PHI

Benefits Plan of the Presbyterian Church (U.S.A.) Medical Plans - Request to Amend PHI

Medical/healthcare

Change of Medical Plan Participation for Mission Personnel

VSP Member Reimbursement

Small Employer Exception (SEE) Package

Healthcare Contributions Only Plan: Salary Reduction Agreement

Medical Continuation Enrollment or Waiver Form

Humana Group Medicare Advantage PPO Enrollment form

Humana Group Medicare Advantage PPO Waiver or Withdrawal form

Evidence of Dependent Disability and Support

Pension Plan

Retirement Pension Application - Former Spouse

The Social Security Leveling Option Agreement

Authorization to Release Pension Information

Tax Withholding Election

Retirement Savings Plan

Retirement Savings Plan of the Presbyterian Church (U.S.A.) (Fidelity Enrollment Form)

Retirement Savings Plan Salary Deferral Agreement

Non-QCCO Discrimination Testing for the RSP

Retirement Savings Plan Employment Change