FORMS

Authorization Release:
Authorization for Release of Information

Reimbursement Forms:
PEHP Flex Spending Reimbursement Form
Prescription Reimbursement or COB Reimbursement Form

HSA:
HSA Direct Deposit Authorization

Opticare:
Opticare Out of Network Claim Online Form
Opticare Out of Network Claim Paper Form

Employee Injuries:
First report of Injury

Life Insurance & Disability:
Certificate Life Insurance – Active Employees
Certificate Accidental Death and Dismemberment – Active Employees
(Policy) Long Term Disability – Active Employees
New York Life Application -AD&D Conversion
New York Life Application – Portability of Voluntary Life
New York Life Application – Life Insurance Conversion
New York Life EOI EZ Link

NOTICES
Chip Notice
Exchange Notice
Jordan School District's Privacy Policy & Practice
Medicare D Creditable Coverage
Glossary of Health Coverage and Medical Terms
2023-24 Traditional Plan Summary of Benefits & Coverage (SBC)
2023-24 Value Plan Summary of Benefits & Coverage (SBC)
2023-24 STAR (QHDHP) Plan Summary of Benefits & Coverage (SBC)
2023-24 Benefit Summary & Master Policy