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

Aflac Certificates:
Aflac Group Accidental Injury Insurance Policy
Aflac Group Critical Illness Insurance Policy
Aflac Group Supplemental Hospital Indemnity Policy
Aflac Employee Enrollment Disclosures

NOTICES
Chip Notice
Exchange Notice
Jordan School District's Privacy Policy & Practice
PEHP Notices
Medicare D Creditable Coverage
Glossary of Health Coverage and Medical Terms
2024-25 Traditional Plan Summary of Benefits & Coverage (SBC)
2024-25 Value Plan Summary of Benefits & Coverage (SBC)
2024-25 STAR (QHDHP) Plan Summary of Benefits & Coverage (SBC)
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)
2024-25 Benefit Summary & Master Policy
2023-24 Benefit Summary & Master Policy