Department of Budget and Management Health Benefits

• ​Affidavit of Domestic Partnership​
  
• ​Affidavit of Dome​stic Partner's Federal Tax Dependent Status & Worksheet
  
• ​Dissolution of Domestic Partnership​
  
• HEARTS FSA Distribution Request
  
• HIPAA Authorization Form
• HIPAA Certificate of Coverage Request Form​
  
• IRS Worksheet to Determine Dependent Support
  
• ​​​​Out of Country Early Refill Prescription Drug Request Form​​
• R
  etiree and COBRA Personal Information Change Form
  ​​
• State Notification of Medicare Information​
  

Helpful Links

• Birth, Marriage, Death Certificates