Check out the website below, for a resource to answer questions regarding Health & Well-being Benefits, Telehealth Service, EAP Counseling, and Provider Contact Information. 

Westmoreland County Healthcare Organization

Important Forms

 2024 - YOUGH SD - 403b Salary Reduction Agreement.pdf 

Accident Incident or Injury Report.pdf  

Additional Work Duty Form.pdf  

Athletic Contest Workers Form.pdf  

 Blank Check Request.pdf 

 Blank Requisition Sheet 2020-2021.xls 

 Election of Health Insurance Withdrawal Buyout - TEACHERS.pdf  

Election of Health Insurance Withdrawal Buyout - AFSCME.pdf  

Election of Health Insurance Withdrawal Buyout - ADMIN.pdf 

 CHIP Model Notice.pdf 

 COBRA General Notice.pdf 

 Daily Conference Request 2024.docx 

Dependent Coverage to Age 26 Notice 4.pdf  

 Field Trip Form 2019-2020.pdf 

 Final Accounting Expense Sheet 2024.doc 

 FMLA Form Employee.pdf 

 FMLA Form Family Member.pdf 

Guidelines for Public Comment 1.pdf 

 Health Insurance Letter 2024-25.pdf 

 Employee Healthcare Selection Form 2024-25 ALL.pdf 

 Marketplace Model Notice 12-31-2026.pdf 

 Health Insurance Withdrawl-Buyout Form.pdf 

 HIPAA Model Notice of Privacy Practices.pdf 

 Nondiscrimination Notice ACA Section 1557.pdf 

 Notice of HIPAA Special Enrollment Rights.pdf 

 Highmark 2023 Preventive Schedule.pdf 

Highmark Website Navigation.pdf

Home Language Survey.pdf 

Homebound Instruction.pdf  

Homebound Teaching Report.pdf 

 Human Resources Tracking Form.pdf 


 Mentor Report Form.pdf  


 403 b Salary Reduction Agreement 2023 16.pdf  

 Medicare Part D Creditable Coverage 2024.pdf 

 Mental Health Parity Act.pdf 

 Mileage Reimbursement Form Updated January 2024.xlsx 

NVA - Yough Benefit Summary.pdf 

NVA Claim Form.pdf 

 Newborns and Mothers Health Protection Act.pdf 

 Overnight Conference Request 2024.doc  

Patient Protection Disclosure.pdf 

 P Card Support Form 22-23.pdf 

Physicians Certificate for Medication.pdf 

Reg Employee Time Sheet.pdf  

Sabbatical Leave Form.pdf  

 Sick Day Bonus 2023-24.pdf 

 School Personnel Health Record Form 2019.pdf 

Sub Time Sheet.pdf  

 Highmark Benefit Summary - PLAN A.pdf  

Highmark Benefit Summary - PLAN E.pdf  

Highmark Benefit Summary - PLAN G.pdf 

 Tuition Reimbursement Packet.pdf 

United Concordia Dental Coverage Information.pdf  

 UPMC Westmoreland Broad Access - FAQs.pdf 

 UPMC Westmoreland Broad Access Grid.pdf 

Voya Financial.pdf  WHCRA Notice 1.docx  

 Womens Health and Cancer Rights Act.pdf 

WS707 Use of Fac.pdf  

WSUse of Facility2014.pdf   

Identogo Instructions.pdf