Claims Forms

Health - Medical / Dental

  • Aetna Medical Claim FORM
  • Aetna Prescription Home Delivery Order FORM
  • Yale Health Plan (YHP) Claim FORM
  • Delta Dental Claim FORM
  • EyeMed Vision Claim FORM

Short Term Disability


Long Term Disability


Flexible Spending Account (FSA) Forms and Tuition Assistance (Reimbursement)

  • Medical/Dental Reimbursement Claim FORM - FSA
  • Statement of Medical Necessity (SOMN) FORM - FSA
  • Dependent/Child Care Reimbursement Claim FORM - FSA
  • Tuition Assistance (Employee) - Education Reimbursement - FSA

Life Insurance Documents

  • Standard Life Insurance - Death Claim FORM

Adoption Reimbursement

  • Adoption Reimbursement Claim FORM

Education Assistance

  • Tuition Reduction Application FORM

PDF format requires Adobe Acrobat Reader which can be downloaded from www.yale.edu/software.