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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
      

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

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)
 

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.