Forms

Health Advocate

Health Advocate Authorization Form 

Cancer Screening

Cancer Screening Form 

JJ Stanis - Dental Claims

Dental Form 

NOTE: Only use this form to make a claim when you use a non-participating dentist OR when you initially go to a participating dentist. This form pertains to all NTA, clerical SRP, administrator bargaining units and retirees that have dental coverage. 

Orthodontic Worksheet (NEW!)

NOTE:  This worksheet can be used to estimate orthodontic treatment costs, insurance benefits, and anticipated out-of-pocket expenses for planning purposes.

Davis Vision - Vision Claims

Vision Claim Form

NOTE: Only use this form to make a claim when you use a non-participating vision provider. 

Excess Major Medical Supplemental Plan 

Excess Major Medical Deductible and Coinsurance Claim Form (needs updating, do not use)

In-Hospital Claim Form (Primary insured benefit only - $50 per night in hospital stay)

These forms, along with their required paperwork, can be submitted as a single PDF to JJ Stanis via email.  

JJ Stanis & WEX - FLEX Spending Account (coming soon)

Flexible Spending Plan Reimbursement Voucher

Flexible Spending Plan Voucher Completion Instructions

Claim Submission Guidelines

Modification to Over The Counter Eligible Expense List for 2011

Eligible Medical Expenses per the IRS

Letter of Medical Necessity

NOTE: The FLEX Spending forms are here for your convenience. IT CAN ONLY BE USED IF YOU HAVE SIGNED UP FOR THIS PLAN THROUGH DISTRICT PAYROLL. YOU MUST BE AN ACTIVE EMPLOYEE.

AFLAC

AFLAC Election Change Form

United Health Care (physician portion of NYSHIP)

United Health Care Claim Form (in state)

United Health Care Claim Form (out of state)

NOTE: Completed claim forms along with the doctor's bill may also be faxed to either of these three numbers:  845-336-7989; 845-336-7747; 845-336-7716

Dependent Student Certification 

Dependent Student Form (Updated Fall 2026)

NOTE: This form must be completed by the college registrar to validate full time enrollment and submitted to JJ Stanis.  Fall semester verification covers 8/1 - 3/31.  Spring semester verification covers 1/1 - 8/31. 

Three Month Extension of Benefits for College Graduate

Extension Form

NOTE: An unmarried dependent student, nineteen years of age or older, but under twenty-five, who graduates from an accredited secondary or preparatory school, college or other educational institution, may continue coverage for up to three months following the end of the month in which course requirements for graduation are completed. There is no extra cost for the extended coverage period, but family coverage must be continued for three months. After the three-month extension, the graduating dependent will be eligible for the full thirty-six months of COBRA coverage. You can find additional information by clicking here.