Forms Online provides IASIS Healthcare employees with instant access to the most recent version of frequently used forms. Use Forms Online to eliminate phone calls, delivery time, and photocopy time and expense. Forms Online is your first stop for self service electronic forms. Select the form you need and print a copy—it’s that easy.

GENERAL EMPLOYMENT
 
  •

W-4 (Updated Annually)
Use this form to withhold the correct federal income
tax from your pay.
     
  • SS-5
Use this form to apply for a new or
a replacement Social Security Card.
     
  • AZ A-4 Form
Use this form to calculate and elect to withhold a
percentage of one's pay for Arizona state tax.
     
  • W-5 Earned Income Credit
Use this form if you are eligible to get part of the earned income credit in advance with your pay and choose to do so
     
     
HEALTH AND WELFARE PLAN FORMS
   
• Medical
   
 
• BCBS – PPO Medical Claim Form
Use this form to file out-of-network medical claim for the $500 PPO
for Tennessee and Louisiana.
   
 
• UMR/UHC - Medical Claim Form
Use this form to file out-of-network medical claims for $500 PPO Plan
for Arizona, Florida, Nevada, Texas and Utah.
   
• Pharmacy
   
 
• Caremark - Mail order Rx Form
Use this form to submit mandatory mail order prescription to Caremark.
• Caremark Drug Reimbursement Form
Use this claim form when you have paid full price for a prescription
drug order at a pharmacy.
• Caremark Prescription Drug Handbook
This sample handbook includes information about your prescription
drug benefit for retail and mail-order services.
   
• Dental
   
 
• Metlife Dental Claim Form
Use this form to file an out-of-network dental claim.
   
• Vision
   
 
• Vision Claim Form
Use this form to file a claim from by a non-network provider.
   
• Flexible Spending Accounts
   
 
• UMR Healthcare Reimbursement Form
Use this form to request reimbursement for eligible healthcare expenses
not paid by insurance.
• UMR Dependent Care Reimbursement Form
Use this form to request reimbursement for eligible dependent care expenses
not paid by insurance.
• Flexible Spending Account Worksheet
Use this worksheet to estimate how much you are likely to spend for
expenses in the coming Plan year.
• General FSA Information
This form contains information about the advantages of FSA, How FSA
works, and how to access my FSA account information.
• FSA Powerpoint Presentation
This powerpoint presentation will inform you about all you need to
know about Flexible Spending Accounts.
   
• Wells Fargo - 401(k) Forms
   
 
• 401(k) Beneficiary Form
Use this form to designate beneficiary(ies) for plan. Please submit completed
form to your Human Resources Department.
• 401(k) Distribution Form
Use this form to request the total distribution of the balance of your 401k Plan account.
   
• Life and Accidental Death and Dismemberment (AD&D)
   
 
• Beneficiary Form
Use this form to designate who will receive the Basic and Voluntary
Group Life Insurance proceeds in the event of your death.  
• Notice of Group Life Conversion
Your employer must complete form and submit to employee to convert
their life insurance policy. This notice must accompany the Employee’s Kit
for Group Life Conversion application.
• Employee's Kit for Group Life Conversion
Use this kit to convert employee and/or dependent Basic or Supplemental Group Life
to an individual life policy with Sun Life Financial. You must have a completed Notice
of Group Life Conversion Form from your employer to send with application.
• Life Claim Packet
Use this packet to file a claim for Life, Accidental Death & Dismemberment (AD&D),
Waiver of premiums, and accelerated benefit claims.
• Voluntary AD&D Claim Packet
Use this information to file a claim for Basic and Voluntary
Accidental Death & Dismemberment (AD&D) benefits.
• Evidence of Insurability
Use this form to provide evidence of insurability for Sun Life
Supplemental employee and dependent life and Long-Term Disability (LTD)
   
• Disability
   
 
  Evidence of Insurability
Use this form to provide evidence of insurability for Sun Life
Supplemental employee and dependent life and Long-Term Disability (LTD)  
• Short Term Disability Claim Packet
Use this packet and form to apply for Short-Term Disability (STD) benefits.
The form must be completed by Human Resources, the employee, and the
employee’s healthcare provider to assist in the determination of STD benefits.
• Long Term Disability Claim Packet
Use this packet and form to apply for Long-Term Disability (LTD) benefits.
The form must be completed by Human Resources, the employee, and the
employee’s healthcare provider to assist in the determination of LTD benefits.
   
   
   
   
   
   
   
   
   

 


IASIS Healthcare