FORMS

BENEFICIARY

To update a beneficiary, please visit hrsystems.azdoa.gov > Y.E.S. Portal.

ENROLLMENT FORMS & GUIDES | 2021

For active employees, enrollment is entirely online via hrsystems.azdoa.gov > Y.E.S. Portal.

Active Employees - 2021

• Guides
  • Active Enrollment Guide 2021 - Guide with enrollment instructions and a simple explanation of each benefit - includes current rates.
  • Active Benefits Guide 2021 - An in-depth look at your benefits to help you use your plan effectively - includes current rates. It Will be posted on December 31, 2020
• Forms
  • Enrollment Form - Active 2021
  • Declaration for Change Form 
  • Appeal Form - Active 2021
• Qualified Life Event (QLE)
  • Qualified Life Event (QLE) and Mid-Year Changes Chart
  • Age 26 Dependent Termination Process

Retirees/LTD - 2021

• Guides
  • Retiree Enrollment Guide 2021 - Guide with enrollment instructions and a simple explanation of each benefit - includes current rates.
  • Retiree Benefits Guide 2021 - An in-depth look at your benefits to help you use your plan effectively - includes current rates. Will be posted on December 31, 2020
• Forms
  • Enrollment Form - Retiree/LTD 2021 
  • Medicare PDP Enrollment Form VibrantRx - Retiree 2021
  • Retiree Appeal Form 2021

COBRA

• Visit the COBRA tab

ENROLLMENT FORMS AND GUIDES | 2020

Active Employees - 2020

Enrollment is entirely online via yesportal.azdoa.gov

• Guides
  • Active Enrollment Guide 2020 - Guide with enrollment instructions and a simple explanation of each benefit - includes current rates.
  • Active Benefits Guide 2020 - An in-depth look at your benefits to help you use your plan effectively - includes current rates.
• Forms
  • Active Enrollment Form 2020
  • Declaration for Change Form 

Retirees/LTD - 2020

• Guides
  • Retiree Enrollment Guide 2020Guide with enrollment instructions and a simple explanation of each benefit - includes current rates.
  • Retiree Benefits Guide 2020 - An in-depth look at your benefits to help you use your plan effectively - includes current rates.

COBRA

• Visit the COBRA tab

QUALIFIED LIFE EVENTS | QLE

• Please see our Qualified Life Events page for forms and filing information. 
• Age 26 Dependent Termination Process

FLEXIBLE SPENDING ACCOUNTS | FSA

• FSA Enrollment Form - Triple Choice Plan | Health Care | Dependent Care - 2021
• FSA Enrolment Form - High Deductible Healthcare Plan (HDHP) | Limited Purpose Dental and Vision | Dependent Care - 2021

HEALTH CARE SPENDING ACCOUNT | HSA

For use with a high deductible healthcare plan (HDHP).  

2021 Forms

• HSA Payroll Deduction Authorization Form - 2021
• How to Calculate HSA Contributions and Maximum Contributions - 2021
• HSA Excess Contributions and Deposit Correction Form

MEDICAL

• Transition of Care Form - 2021

PHARMACY

 MedImpact - Active

• MailOrder Pharmacy Form - Active

Vibrant Rx - Retiree

• Medicare PDP Enrollment Form VibrantRx 2021 - Retiree