Employees

Benefit Forms

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.
  • Direct Deposit Form
    Use this form to have your pay deposited directly to your checking or savings account.

Health and Welfare Plan Forms

Meritain Health Forms

Pharmacy

  • OptumRx – Claim Form
    Use this form for reimbursement when you have paid full price for a prescription drug order at your pharmacy.
  • OptumRx – Home delivery
    Register on the Optum Rx website for information on ordering maintenance drugs for home delivery.  You can order online, your doctor can use ePrescribe, you can call it in or print a form for mailing.
    How to register for the OptumRx website  – Use the member ID number found on your Meritain medical card
    Mailorder  Form
  • OptumRx – Formulary Exclusion List
    This is the listing of drugs which are excluded from our Formulary so they are not covered.
  • OptumRx Formulary
    This is the listing of drugs covered under the Optum Formulary.
  • OptumRx Specialty Drugs with BriovaRx
    BriovaRx will handle all your specialty medication needs.  Call 1-855-427-4682 or visit the BriovaRx.com website.  Their patient care coordinators and pharmacists will work with you to understand and manage your medications and coordinate shipping your medication wherever you need it.

Dental

Vision

Flexible Spending Accounts

Wells Fargo – 401(k) Forms

  • 401(k) Beneficiary Form
    Contact Wells Fargo directly via the website or 800 number or use this form to designate beneficiary(ies) for plan and submit completed form to your Human Resources Department.
  • 401(k) Distribution Form
    Contact Wells Fargo directly at 800-728-3123 to request the most recent Distribution Form.
  • 401(k) Rollover Contribution Form
    Contact Wells Fargo directly at 800-728-3123 to request to roll money from another eligible account to the Wells Fargo account.

Life and Accidental Death and Dismemberment (AD&D)

Disability

Voluntary Benefits

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