Montgomery County Public Schools

Employee and Retiree Service Center → Retirees → Forms

Forms

Find a form to access your benefits, make changes, and more.

Health benefits

Enroll in benefits

• MCPS Form 455-22: Retiree Benefit Plan Enrollment
  Submit within 60 calendar days of your retirement, or during annual open enrollment each fall.
•  UnitedHealthcare Medicare crossover enrollment form
  UnitedHealthcare participants must submit after receiving Medicare card with Parts A and B to continue enrollment in UnitedHealthcare benefits.

Medical Forms

• CareFirst BlueChoice HMO Primary Care Physician Selection Form 
• UnitedHealthcare Claim Form 
• UnitedHealthcare International Claim Form 
• UnitedHealthcare Provider Nomination Form 

Prescription Forms

• CVS/Caremark Mail Order Pharmacy Order Form 
• CVS/Caremark Claim Form 

Dental Forms

• Aetna Dental PPO Claim Form 

Vision Forms

• NVA Claim Form 

Personal Information

• MCPS Form 445-1: Change in Personal Information 
  Update your address and contact information.
• State form 77: Maryland State Retirement Agency Retiree Change of Address Form
  State Core Pension Plan members update your address and contact information with the State.

Life Insurance

• MCPS Form 455-22: Retiree Benefit Plan Enrollment
  Submit to change your life insurance beneficiaries.

Pension Payments

State Core Plan Forms

• Direct Deposit Form 
• SRA Federal and Maryland State Tax Withholding Form 

MCPS Core Plan Forms

• Aetna Direct Deposit Form 
• MCPS Form 281-50: Federal and Maryland State Tax Withholding Form