Benefit Forms

Cigna Dental Claim Form (pdf) Cigna Dental HMO Brochure (pdf) Cigna Dental HMO Patient Charge Schedule (pdf) Cigna Dental HMO Plan (pdf) Cigna Dental PPO Plan (pdf) Cigna Dental PPO Summary of Benefits (pdf) Cigna PPO Dental Brochure (pdf)

Cigna Center of Excellence (pdf) Cigna Continuity of Care Form (pdf) Cigna Find a Doctor Brochure (pdf) Cigna LocalPlus Summary of Benefits Coverage (pdf) Cigna LocalPlus Summary Plan Description (pdf) Cigna MDLive Registration (pdf) Cigna Medical Claim Form (pdf) Cigna OAP + HSA Summary of Benefits Coverage (pdf) Cigna OAP + HSA Summary Plan Description (pdf) Cigna OAP In-Network Summary of Benefits Coverage (pdf) Cigna OAP In-Network Summary Plan Description (pdf) Cigna OAP Summary of Benefits Coverage (pdf) Cigna OAP Summary Plan Description (pdf) Cigna Preventive Care Guide (pdf) Cigna Urgent Care (pdf) Cigna Wellness Screening Form (pdf) Dependent Verification Form (pdf) Identity Force (pdf)

Cigna Pharmacy Integration (pdf) Cigna Prescription Drug Claim Form (pdf) Cigna Prescription Home Deliver Order Form (pdf) Cigna Prescription Home Deliver Order Form (pdf) Cigna Standard 3-Tier Prescription Drug List (pdf)

STD Insurance Certificate (pdf) STD Insurance Policy (pdf)

Domestic Partner Affidavit (pdf)

Cigna Mental Health Care Kit (pdf) EAP Telehealth Behavioral (pdf) EAP with MDLIVE (pdf)

FSA Claim Form (pdf) FSA Debit Card Application (pdf) FSA Health Care Expense Planning Worksheet (pdf)

City of Scottsdale Group Health Plan Privacy Notice (pdf) HIPAA Privacy Complaint Form (pdf) PHI - Authorization to Use or Disclose (pdf) PHI - Request for Accounting of Plans Disclosures of Protected Health Information (pdf) PHI - Request for Confidential Transmission of Protected Health Information (pdf) PHI - Request for Restrictions on Use & Disclosure of Protected Health Information (pdf) PHI - Request to Amend (pdf) PHI - Request to Inspect and Copy Protected Health Information (pdf) PHI - Revocation of Authorization for the Use and Disclosure of Protected Health Information (pdf)

FMLA & STD Employee Procedures (pdf) FMLA Rights and Responsibilities (pdf) How to file a Disability Claim (pdf) Medical Leave of Absence Notification Form (pdf) Paid Parental Leave Program Highlights (pdf) Return to Work Evaluation Form (pdf)

Basic Life Insurance Certificate (pdf) Beneficiary Designation/Change Form for Life and Vol Life (pdf) CIGNA Life Insurance Conversion Form (pdf) Name Change Form (pdf) Summary of Benefits - Basic Life Insurance (pdf) Summary of Benefits - Voluntary Life Insurance (pdf) Travel Accident Insurance Certificate (pdf) Voluntary Life Insurance Certificate (pdf) Voluntary Life Insurance Enrollment/Change Form (pdf)

Pet Insurance Plan Summary (pdf)

PEHP Claim Form (pdf) PEHP Fact Sheet (pdf)

ASRS Presidential Callup (pdf) ASRS Return To Work (pdf) PSPRS Beneficiary Change Form (pdf)

Cigna Hearing Program Flier (pdf) VSP Eyeconic (pdf) VSP Hearing (pdf) VSP Vision Care Coverage (pdf)