Forms and Documents

The documentation is provided is in the Adobe Acrobat™ file format. You will need to have the free reader program installed on your computer to view and print the documentation. If you do not have the reader installed, you can click the button to the right to install it.
 
General Documents
PDF

2016 Employee Benefits Guide

Flexible Benefits Plan Document

Health Care Reimbursement Plan
Unum Beneficiary Designation Form
2016 Domestic Partner Affidavit
Tuition Reimbursement Application
Tuition Reimbursement Guidelines
Health Care Reform and You - Fact Sheet
2014 Summary Annual Report Dental Vision Life Insurance Plan 507
2014 Summary Annual Report Healthcare Plan 501
2016 Important Notices, Including Notice of Exchange & Medicare Part D Notice of Credible Coverage
Medical, Dental, Vision and Pharmacy Documents
PDF
Employee Health Care Plan
Huntington Choice Medical Plan Summary Plan Description
Huntington Choice Medical Plans Plan Document
2016 Summary of Benefits & Coverage (SBC) - Plan Option A
2016 Summary of Benefits & Coverage (SBC) - Plan Option B
Medical Claim Form / Keenan HealthCare
Health Care Reform FAQ
EOC – Dental
EOC – Group Vision Care Plan
Express Scripts Prescription Reimbursement Claim Form
VSP Member Claims Out Of Network Fax Form
VSP Grievance Process
Anthem Provider Instructions
Keenan Health Care Individual & Family Plans Flyer

Life / Long Term Disability
PDF
LTD Benefit Summary
UNUM LTD SPD
UNUM Life and AD&D SPD


Express Scripts
PDF
Express Scripts Prescription Reimbursement Claim Form
2016 Express Scripts National Preferred Formulary
California Providers
FAQs

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Retirement Benefits
PDF
Social Security Online Application Information
Huntington QDIA Notice 2013
Notice of Determination Letter 403B
Defined Benefit Plan 2012
First Amendment to Retirement Plan
Second Amendment to Retirement Plan
Savings Plan Summary Annual Report
Huntington Memorial Hospital DC QDRO Guidelines

PTO
PDF
Paid Time Off - Paid Time Off Cash-Out (PTO) Policy

Voluntary Benefits

PDF
Sprint Special Pricing for Huntington Hospital Employees
Sprint Special Pricing
AT&T Special Pricing for Huntington Hospital Employees
AT&T Special Pricing
Verizon Special Pricing for Huntington Hospital Employees
Verizon Special Pricing
LegalShield Application
LegalShield Application

Flexible Spending Account
PDF
FSA Reimbursement Request Form
HFSA Eligible Expenses
Keenan Flex-Care Benefit Card overview
2013 Keenan FlexCare Section 125 Flexible Spending Account Update
Understanding Your Flexible Spending Plan
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