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Benefits

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Forms

  1. Health and Welfare Change Forms
  2. Medical/Prescription/Mental Health/Vision Forms
  3. Health Care and Dependent Care Spending Account Forms
  4. Delta Dental Forms
  5. Retirement Plan Forms
  6. Other Benefit Forms

 

Health and Welfare Change Forms

You may add or remove a dependent in the event of a qualified status change. You are encouraged to review the status change definitions before downloading the form; in some cases supporting documentation is needed. You must add or remove a dependent within 31 days of the status change.

To add or remove a dependent from your coverage, please log onto our enrollment system, bSwift (www.scripps.bswift.com) using your user ID and password. Click here for a bSwift user guide. You must also provide proof of dependency if adding a dependent to the plan. For additional bSwift support, please contact Benefits Administration at 858-784-8487.


Medical/Prescription/Mental Health/Vision Forms

Aetna Medical Reimbursement Form (PPO, HDHP PPO, HMO,EPO, Graduate Student Plans only)   

Aetna Prescription Claim Form (HMO and EPO Plans  )

OptumRx Prescription Mail Order Form (PPO, HDHP PPO, and Graduate Student Plans Only)

OptumRx Prescription Reimbursement Claim Form (PPO, HDHP PPO, and Graduate Student Plans Only)

Medical Waiver Form (All Medical Plans)

Medical Eye Services Vision Claim Form (California Participants only)

Flexible Spending Account Forms

All FSA claims are filed online at www.PayFlex.com

Delta Dental Forms

Delta Dental Reimbursement Form

Retirement Plan Forms

Cash Balance retirement plan forms

Cash Balance Beneficiary Designation Form

Deferred Compensation (457(b)) Retirement Plan Forms

Fidelity Investments Beneficiary Designation Form

Fidelity Distribution Automatic Payments Form

Fidelity Distribution Cash Payout Form

Faculty and Management Retirement (401(a)) Retirement Plan Forms

Fidelity Investments Beneficiary Designation Form

Fidelity Transfer/Rollover/Exchange Form

Fidelity Distribution Automatic Payments Form

Fidelity Distribution Cash Payout Form

Fidelity Distribution Rollover Form

Employee retirement (401(a)) plan forms

Fidelity Investments Beneficiary Designation Form

Tax Sheltered Annuity (403(b)) Plan Forms

Fidelity Investments Beneficiary Designation Form

Fidelity Transfer/Rollover/Exchange Form

Fidelity Distribution Automatic Payments Form

Fidelity Distribution Cash Payout Form

Fidelity Distribution Rollover Form

Other Benefit Forms

Injury/Illness/Incident Report

Prudential Group Term Life Beneficiary Form

Transit Benefit Enrollment Form

Prudential Voluntary Life/AD&D Beneficiary Form