Forms

Medical, Dental and Prescription

Blue Cross

• HIPAA Authorization form
• Mail Order RX form
• Medical Claim form
• Member Grievance form
• Prescription Claim form

Kaiser

• Emergency Medical Claim form
• HIPAA Authorization form

PacificCare DMO

United Healthcare PPO Dental

• Claim Form
• Temporary ID Card

Disability and Life Insurance

Long Term Disability

• Claim Form

Life Insurance

• Designation of Beneficiary form
• Life Insurance claim
• Statement of Health form

Accidental Death & Dismemberment (AD&D)

• AD&D Claim form
• Designation of Beneficiary form

Health Care and Dependent Care Reimbursement Accounts

• Dependent Care FSA Claim form
• Direct Deposit form
• Health Care FSA Claim form
• Payment Card Request form

Transportation Spending Account

•  Claim Form

•  Direct Deposit form

Retirement

403(b) Plan

• USD Salary Reduction Agreement
• Fidelity
  • Fidelity Enrollment Guide
  • Fidelity 403b Enrollment Form
  • Fidelity Transfer Rollover Form and Instruction
• TIAA-CREF
  • Enrollment form (USD contributions)
  • Enrollment form (Voluntary employee contributions)
  • Designation of Beneficiary form                   
  • Instructions for Address Change
  • Transfor or Rollover Authorization form
• AIG VALIC
  • Enrollment form
  • Change form
• DWS – Scudder

• Distribution Forms
  • Final Distribution form
  • In-Service Distribution form
• Loan Forms
  • Loan Payoff

457(b) Plan

• 457(b) Deferral Contribution Election form