benefit forms
Active Employee Plans
- 2017 Changes
- Benefits Changes Overview
- Benefits Enrollment Guide
- Benefits Summary (Medical Plans Comparison)
- Employee Paid Medical Rates
- Medical
- ABOUT Generic Drugs
- Best Doctors
- HRA VEBA Flyer
- Kaiser Care now at a Target Near You
- Kaiser Virtual Care Flyer
- Now Clinic
- Optum HRA EE
- Preventative Care Services
- VEBA Welcome Flyer
- VEBA PPO provider search flyer
- VEBA Top 10 Benefits
- VEBA UHC Performance HMO Find a Doctor
- UHC Virtual Care Flyer
- Medical Plan Summaries
- Kaiser Benefits Summary
- United Healthcare Performance HMO Plan Brochure Overview
- United HealthCare Performance Network 1 Summary of Benefits Coverage
- United HealthCare Performance Network 2 Summary of Benefits Coverage
- United HealthCare Performance Network 3 Summary of Benefits Coverage
- United Healthcare Alliance HMO Summary of Benefits Coverage
- United HealthCare PPO Select Plus SD Summary of Benefits
- United HealthCare Non-Differential Summary of Benefits Coverage
- United HealthCare Out-of Area EPO Summary of Benefits Coverage
- United HealthCare Out-of Area PPO Summary of Benefits Coverage
- VEBA Out of Area Dependent Benefits
- Medical Forms
- Dental
- Delta Dental Mobile
- Dental Plan Summary
- Dental Forms
- Vision
- Acupuncture/Chiropractic
- OptumHealth Acupuncture & Chiropractic Benefits
- Acupuncture & Chiropractic $10 Schedule of Benefits
- Acupuncture & Chiropractic $20 Schedule of Benefits
- Acupuncture & Chiropractic $30 Schedule of Benefits
- Express Scripts Prescriptions (UHC Plans only)
- Express Scripts HMO Alliance Co-Payments
- Express Scripts Prescription Overview
- Express Scripts Network 1 Co-Payments
- Express Scripts Network 2 Co-Payments
- Express Scripts Network 3 Co-Payments
- Express Scripts PPO Co-Payments
- Employee Assistance Program
- Hyatt Legal Plan
Adjunct Benefit Qualification
Beneficiary Designation Forms
- Beneficiary Designation for Deceased Employee
- CalPERS Beneficiary Designation
- Recipient Designation Form CalSTRS
- Prudential Beneficiary Designation Change Form
Domestic Partner
- Overview of Health Coverage for Domestic Partners
- Affidavit of Domestic Partnership
- Health Care Enrollment Statement
Flexible Spending Account (FSA) administered by Benefit Coordinators Corporation (BCC)
- Account Brochure
- Debit Card Request Form
- Direct Deposit Form
- Eligible Expenses
- Flex Enrollment Form
- FSA Plans: Grace Period
- My SmartCare Mobile App
- Notice of Change or Termination
- Over-the-Counter (OTC)
- Reimbursement Request Form
- SmartCare Registration
General Benefit Forms
Insurance Waivers
Long Term Disability Insurance (for Classified Contract Employees Only)
Prudential Life Insurance