ScottsdaleAZ.Gov

Employee Forms - In alphabetical order

Address Change Form

ASRS Forms      ASRS Presidential Callup Form

ASRS Return to Work Form

ASRS Beneficiary Change Form        ASRS Change of Address Form

Credit Card Authorization for Retiree/COBRA premium payments

Dental Claim Forms        Assurant Dental (formerly Fortis)             Delta Dental Claim Form

Domestic Partner Affidavit

Emergency Contact Change Form

Enrollment Forms      Benefits Change Form        Open Enrollment Form FY 08-09

Flexible Spending Account Forms     2008 FSA Brochure       2008 FSA Enrollment Form               Claim Form      Direct Deposit Request Form      FSA Debit Card Application

Health Claim Forms      Aetna               MMSI

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 Account Change Form              ICMA Roth IRA Application Form              ICMA 457 Rollover Packet & Forms

Leave Of Absence Notification   Return to Work Evaluation

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

Name Change

Paycheck Direct Deposit Enrollment         (Xls / 37KB / 1 page)

Payroll Tax Forms      W4 - 2008 Tax Form              Arizona A-4 Form        (PDF / 87KB / 2 pages)

Prescriptions - Mail Order Forms      Aetna      Mayo

Public Safety Personnel Retirement System Forms (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 hr@ScottsdaleAZ.gov
• Stop by one of our offices (7575 E. Main St or at the Corporation Yard)

This guide 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 in this guide differs from the amount of benefit actually provided by the policy or plan, the terms of the legal documents will control.