Employee Benefits Forms

 

List of Benefits Forms

Please contact the Benefits Office at (480) 644-2299 if you require assistance.

Please print a copy and forward the completed signed original to the Employee Benefits Office for processing.  Be sure to make a copy for your records.

 

 

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Employee Benefits
20 E Main Street, Suite 600
Mesa, AZ 85201
Office hours:
Mon -Thurs 7am-6pm
(480) 644-2299 - Phone
(480) 644-4548 - Fax

Option 1: Medical Plan

Ameriben

-Verification & Coverage

-Claim Status

-Pre-certification

-Disease & Case Management

-Medical Appeals

-Request Medical/Prescription Card

Option 2: Prescription Plan

CVS Caremark

 -Prescription Coverage

-Authorizations

-Appeals

Option 3: Dental Plan

Delta Dental

-Verification & Coverage

-Claims

-Appeals

-Request Dental Card

Option 4: 2015 FSA

ConnectYourCare

-Claims

-FSA Balance

-Request FSA Card

-Appeals

Option 5: Eligibility - Active Employees 

-New Hires

-COBRA

-Qualifying Events

Option 6: Eligibility - Retired Employees

-Premium Information

-Qualifying Events

-COBRA

 Option 7: General Questions

Option 9: 2014 FSA- Benefits Office


E-mail (password resets cannot be done via email)

Forms

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