Open Enrollment Information and Forms

The month of May is designated as an open enrollment period for health, dental and related dependent care and medical expenses covered under the IRS125 plan.

If you have been thinking of making any changes in your provider or family status, May is the only month in which you are allowed to make these changes without the benefit of a qualifying event.

The open enrollment period  is Wednesday, May 3 to May 21, 2021.

If you are making changes, please submit the forms to the business office.

If you are making changes and are an active employee, please submit to the forms to  Martha Moran at If you are a retiree, please submit your form to Diane Hartman at

The forms below are provided in PDF format. If you encounter any difficulty attempting to access these files, contact Robert Hanlon at

Forms and Downloadable Information


  • Blue Shield PPO
  • Blue Shield Point of Service
  • CDPHP Universal Benefits
    • Flexible Spending Accounts

    4/30/2021 – Please be advised that the IRS has increased the maximum allowable amount for the medical expense annual election. The annual election maximum for medical expense is increasing to $2,750.00. Scotia- Glenville CSD will be adopting this maximum for the July 1, 2021 – June 30, 2022 year. Dependent care will remain the same at $5000.00.