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Employee Benefit Forms

Employee Forms - In alphabetical order

      Address Change Form

ASRS Forms
     ASRS Presidential Callup Form

     ASRS Return to Work Form

Dental Claim Forms
    Assurant Dental (formerly Fortis)leavingcos.gif (340 bytes)
    Delta Dental Claim 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

     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 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

Prescriptions - Mail Order Forms
     Aetna leavingcos.gif (340 bytes)

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

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

Need assistance or have questions?

  • Contact Human Resources at (480) 312-7600
  • Send an email to hrbenefitsemail@ScottsdaleAZ.gov
  • Stop by one of our offices (7575 E. Main St or at the Corporation Yard)


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.