Employee and Retiree Service Center → Retirees → Forms

Forms

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

Health benefits

Enroll in or change benefits

• MCPS Form 455-22R: Retiree Benefit Plan Enrollment for New Retirees Only
  Submit with your retirement application packet.
• MCPS Form 455-22: Retiree Benefit Plan Enrollment
  Submit if you are making changes to your benefits during Open Enrollment, within 60 days of your retirement, or after experiencing a qualifying life event. In addition, use this form to update your beneficiaries.
• Kaiser Permanente Group Medicare Enrollment Form
• Kaiser Permanente Medicare Health Plan Disenrollment Form
  Required when cancelling or transferring to another medical plan.

Medical forms

• CareFirst BlueChoice HMO Primary Care Physician Selection Form
• CareFirst Biometric Screening Physician Form

Prescription forms

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

Dental forms

• CareFirst Dental PPO Claim Form

Vision form

• Davis Vision (provided through CareFirst) Claim Form

Personal Information

• MCPS Form 445-1B, Change in Personal Information for MCPS Retirees and Former Employees 
  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