Medical, Dental, & Vision Forms

Cigna Medical Claim Form

Cigna Pharmacy Claim Form

Cigna Dental PPO Claim Form

VSP Out-Of-Network Claim Form

Health Savings Accounts & Flexible Spending Accounts Forms

HSA Change Form  

HSA Deposit Slip

Dependent Care Flexible Spending Account Claim Form

Short Term Disability & Long Term Disability Forms

Long Term Disability Application      
Short Term Disability Claim Form

Short-term disability Summary of Benefits

Life Insurance Forms

Sun Life Evidence of Insurability Form (online submission - enter group # 213993)    

Sun Life Evidence of Insurability Form (Effective 10/1/2017 -online submission - enter group # 900851)  

Sun Life Evidence of Insurability Form (paper form) 

Group Life and Accidental Death Dismemberment Certificate of Coverage

Sun Life Death Claim

Benefit Guide and Summary Plan Description 

Benefits Guide for contract employees for the 2016/2017 plan year            

Mesa Public Schools Benefits Plan Document/Summary Plan Description

Flex Benefits Program Summary Plan Description   

Mesa Unified School District #4 403(b) Plan Document   
TDA Dental HMO Coverage and Copayments   
Cigna Dental PPO Coverage Summary    

Summary of Benefits and Coverage

OAP SBC

HDHP 2500 SBC

HDHP 1500 SBC

2017 - 2018 Plan Year

OAP SBC

HDHP 2500 SBC

HDHP 1500 SBC

 

TSA Consulting Services for 403(b), Roth 403(b) and 457(b) 

 

General Benefit Documents

IRS Health Care Eligible Expenses
Long Term Disability Income Plan

ASRS Forms

ASRS Beneficiary Form 

ASRS Address/Name Change Form                                                                                                                

Other

Medicare Part D Notice of Creditable Coverage

HIPAA Privacy Notice

HIPAA Privacy PHI Authorization Form

HIPAA - Appoint a Personal Representative Form

United Pet Care Member Change Form

United Pet Care Website