Forms

• Aetna Medical Claim Form
• Aetna Dental Claim Form
• PayFlex Claim Form (Flexible Spending Accounts)
• CVS Caremark Prescription Reimbursement Claim Form
• EyeMed Vision Claim Form
• Tobacco Cessation Physician Affidavit Form
• Tier Zero Prescription Drug List
• Maintenance Drug List
• Preventive Care List

Tuition Reimbursement Application & Tracking (online form)

Faculty and Staff

• Life Insurance Evidence of Insurability (EOI) Form (online form)

• For changes to beneficiaries, use Self-Service. View instructions.

Emory Clinic

• Life Insurance Evidence of Insurability (EOI) Form (online form)

Retirees

• Life Insurance Change of Beneficiary Form

Faculty and Staff

• Long Term Disability Claim Form
• Long Term Disability COLA (Cost of Living Adjustment) Enrollment Form

Medical House Staff

• Long Term Disability Claim Form

Faculty and Staff

• Investment Performance Chart

457(b) Plan

• 457(b) Deferred Compensation Agreement Form
• 457(b) Fidelity Enrollment Form
• 457(b) TIAA Enrollment Form
• 457(b) Vanguard Enrollment Form

403(b) Savings Plan and 403(b) Roth

• For the 403(b) Savings Plan and 403(b) Roth, use Self-Service to enroll, enter your contribution amounts, and select your vendors.

Medical House Staff

• Investment Performance Chart

403(b) Savings Plan and 403(b) Roth

• For the 403(b) Savings Plan and 403(b) Roth, use Self-Service to enroll, enter your contribution amounts, and select your vendors.

Emory Clinic

• Investment Performance Chart

457(b) Plan Forms

• 457(b) Deferred Compensation Agreement Form
• 457(b) Fidelity Enrollment Form
• 457(b) TIAA Enrollment Form
• 457(b) Vanguard Enrollment Form

403(b) Savings Plan and 403(b) Roth

• For the 403(b) Savings Plan and 403(b) Roth, EC members can enroll  on Fidelity Investment's website.

• FMLA and Medical Leave Request Form (online form)
• FMLA Return to Work Form
• Non Medical Leave Request Form
• Timekeeping Instructions and Forms (log-in required)
• Payroll Forms (log-in required)

The application packets below are provided for informational purposes only. If the deadline on the form has passed, wait until the next round opens up before completing.

• Administrative Professionals Program Application
• Aspiring Leaders at Emory Program Application
• Essentials of Leadership at Emory Program Application
• HR Rep Certification Program Application (accepted on a rolling basis)
• Mentor Emory Program Application (mentee)
• Mentor Emory Program Application (mentor)

• Adoption Reimbursement Request Form
• Childcare Subsidy Application Form

• Diabetes Prevention Program Interest Form
• Tobacco Free Emory Anonymous Reporting Form
• Request for Ergonomic Evaluation Form

• Employment Verification Authorization Form
• Personal Information Change Form
• Exit Interview Survey Form