AFFORDABLE CARE ACT | 1095C Reprint Form
- To update a beneficiary, please visit hrsystems.azdoa.gov > YES Portal > Your Employee Benefits > Benefits > Beneficiaries.
- State Employee Information Organizer (Being Prepared) - This guide from Human Resources provides information on steps for your loved ones to take in the event you pass away while employed by the State.
ENROLLMENT FORMS & GUIDES
For active employees, enrollment is entirely online via hrsystems.azdoa.gov > YES Portal.
- Active Enrollment Form | 2023
- Active Appeal Form | 2023
- Declaration for Change Form
- Qualified Life Event (QLE)
- The following events can be processed online: birth, adoption, marriage, divorce, and legal separation. See the QLE page.
- Visit the COBRA tab
FLEXIBLE SPENDING ACCOUNTS | FSA
- FSA Healthcare - for use with Triple Choice Plan | 2022| 2023
- FSA Limited Purpose (Dental & Vision) - for use with High Deductible Healthcare Plan (HDHP w/HSA) | 2022 | 2023
- FSA Daycare/Eldercare | 2022 | 2023
HEALTH CARE SPENDING ACCOUNT | HSA
For use with a high deductible healthcare plan (HDHP).
- HSA Payroll Deduction Authorization Form | 2022 | 2023
- How to Calculate HSA Contributions and Maximum Contributions Guide | 2022
- HSA Contribution Cancellation Request Form
- HSA Excess Contribution Cancellation Request Form
- HSA Transfer Account to Optum Bank Form
PRESCRIPTION DRUG | PHARMACY
- Active - MedImpact Mail Order Pharmacy Form
- Active - MedImpact Reimbursement Form
- Retiree - Vibrant Rx Medicare PDP Enrollment Form | 2022 | 2023
- Retiree - Vibrant Rx Medicare PDP Disenrollment Form | 2022 | 2023
COVID At-Home Test Reimbursement
- Reimbursement Rules
- Blue Cross Blue Shield COVID At-Home Test Reimbursement Form
- UnitedHealthcare COVID At-Home Test Reimbursement Form
TRANSITION OF CARE
- Transition of Care | 2023