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Employee Benefit Forms

Employee Forms - In alphabetical order


ASRS Forms

ASRS Presidential Callup Form

ASRS Return to Work Form

Dependent Verification Form               

Domestic Partner Affidavit

Emergency Contact Change Form

Enrollment Forms
Benefit Change Form


Flexible Spending Account Forms
Claim Form 

Direct Deposit Request Form 

FSA Debit Card Application

Health Claim Forms

HSA Change Form

HSA Change Form 2015

Aetna Rx Claim Form (pdf/294kb/2pp)    

Level Three Claims Appeal Process (pdf/165kb/3pp)


HIPAA Privacy Notice
Use/Disclosure Authorization
Revocation of Authorization for the Use & Disclosure of PHI
Request for Confidential Transmission of PHI
Request for Restrictions on Use & Disclosure of PHI
Request to Inspect & Copy PHI
Request to Amend PHI
Request for Accounting of Plan's Disclosures of PHI
Privacy Complaint Form

ICMA Forms

ICMA Change Form

ICMA Change Form 2015
ICMA 457 Beneficiary Change Form
ICMA Roth IRA Application Form
ICMA Roth Change Form
ICMA 457 Rollover Packet & Forms

Leave Forms

Leave Of Absence Notification

Return to Work Evaluation

Life Insurance

Beneficiary Change Form for Life and Vol Life    
Voluntary Life Insurance Change Form

Name Change

Cigna Prescription Order Form

Public Safety Personnel Retirement System

Public Safety Personnel Retirement System Formsleavingcos.gif (340 bytes)
PSPRS Beneficiary Change Form

Surepay Retiree/COBRA Automatic Payment Enrollment Form (PDF/ 107KB / 1 pg)

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Produced by Human Resources
This information represents a summary of benefits provided by the City of Scottsdale to benefited employees. Every effort has been made to report information accurately. All information, including the amount of any benefit and employee eligibility of benefits, is subject to and governed by the terms and conditions of the applicable policy or plan documents. In all cases where any of the information provided differs from the amount of benefit actually provided by the policy or plan, the terms of the legal documents will control.