FORMS
AFFORDABLE CARE ACT | 1095C Reprint Form
BENEFICIARY
To update a beneficiary, please visit hrsystems.azdoa.gov > YES Portal > Your Employee Benefits > Benefits > Beneficiaries.
ENROLLMENT FORMS & GUIDES
For active employees, enrollment is entirely online via hrsystems.azdoa.gov > YES Portal.
Active Employees
- Guides
- Active Enrollment Guide - with enrollment instructions and a simple explanation of each benefit - includes current rates. | 2022
- Active Benefits Guide - an in-depth look at your benefits to help you use your plan effectively - includes current rates. | 2022 (available 1/31/2022)
- Forms
- Active Enrollment Form | 2022
- Active Appeal Form | 2021 | 2022
- Declaration for Change Form
- Qualified Life Event (QLE)
- Guides
- Retiree Enrollment Guide - With enrollment instructions and a simple explanation of each benefit - includes current rates. | 2022
- Retiree Benefits Guide - An in-depth look at your benefits to help you use your plan effectively - includes current rates. | 2022 (available 1/31/2022)
- Forms
COBRA
- Visit the COBRA tab
FLEXIBLE SPENDING ACCOUNTS | FSA
- FSA Healthcare - for use with Triple Choice Plan | 2021 | 2022
- FSA Limited Purpose (Dental & Vision) - for use with High Deductible Healthcare Plan (HDHP w/HSA) | 2021 | 2022
- FSA Daycare/Eldercare | 2021 | 2022
HEALTH CARE SPENDING ACCOUNT | HSA
For use with a high deductible healthcare plan (HDHP).
Forms
- HSA Payroll Deduction Authorization Form | 2022
- 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 Form | 2022
TRANSITION OF CARE
- Transition of Care | 2022
