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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 2014-15                 
                     

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 (2013/2014)

Aetna 
            
HSA Change Form

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

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

HIPAA Forms

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 
         
Cigna Prescription Order Form

Public Safety Personnel Retirement System

Public Safety Personnel Retirement System Formsleavingcos.gif (340 bytes)
(www.psprs.com)
 
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.