Medical Forms

SISC Membership Change Form
File Size:	201 kb
File Type:	pdf

Download File

---

uusd_10thly_rates.pdf
File Size:	170 kb
File Type:	pdf

Download File

---

uusd_11thly_rates.pdf
File Size:	119 kb
File Type:	pdf

Download File

---

uusd_monthly_12_rates.pdf
File Size:	119 kb
File Type:	pdf

Download File

---

How to Find a PPO/In Network Anthem Provider
File Size:	139 kb
File Type:	pdf

Download File

---

Anthem Member Claim Form (for reimbursement)
File Size:	41 kb
File Type:	pdf

Download File

---

Plan G1 & G2 Summary of Benefits 2018/19
File Size:	142 kb
File Type:	pdf

Download File

---

Plan G1 & G2 Medical Benefit Booklet 2018/19
File Size:	1799 kb
File Type:	pdf

Download File

---

Plan K Summary of Benefits 2018/19
File Size:	143 kb
File Type:	pdf

Download File

---

Plan K Medical Benefit Booklet 2018/19
File Size:	1806 kb
File Type:	pdf

Download File

---

Plan M Summary of Benefits 2018/19
File Size:	141 kb
File Type:	pdf

Download File

---

Plan M Medical Booklet 2018/19
File Size:	1810 kb
File Type:	pdf

Download File

---

Health Plan Change Form 2018/2019
File Size:	607 kb
File Type:	pdf

Download File

---

MD Live Medical + Behavioral Health - Telemedicine Visits for $5
File Size:	733 kb
File Type:	pdf

Download File

---

Advanced Medical: Expert Medical Opinion
File Size:	581 kb
File Type:	pdf

Download File

---

Health Plan Comparison Grid 2018/2019
File Size:	605 kb
File Type:	pdf

Download File

---

Free Hip, Knee & Spinal Surgery Program
File Size:	540 kb
File Type:	pdf

Download File

---

---

Prescription Forms

Dental Forms

Navitus Prescription Drug Claim Form
File Size:	40 kb
File Type:	pdf

Download File

---

Navitus Pharmacy Booklet
File Size:	413 kb
File Type:	pdf

Download File

---

Navitus Contact Sheet
File Size:	77 kb
File Type:	pdf

Download File

---

Costco Rx Mail Order Brochure
File Size:	334 kb
File Type:	pdf

Download File

---

Costco Rx Mail Order Registration
File Size:	169 kb
File Type:	pdf

Download File

---

Evidence of Pharmacy Benefit
File Size:	444 kb
File Type:	pdf

Download File

---

---

Delta Dental Claim for Reimbursement
File Size:	375 kb
File Type:	pdf

Download File

---

Delta Dental Summary of Benefits & Coverage (effective October 1, 2015)
File Size:	515 kb
File Type:	pdf

Download File

---

---

Vision Forms






​

Employee Assistance Program (EAP) 

Summary of MES Vision Benefits
File Size:	48 kb
File Type:	pdf

Download File

---

Vision Claim Form (English)
File Size:	64 kb
File Type:	pdf

Download File

---

Vision Claim Form (Spanish)
File Size:	34 kb
File Type:	pdf

Download File

---

---

Employee Assistance Program Flyer
File Size:	806 kb
File Type:	pdf

Download File

---

Basic Life Insurance
$20,000 policy included in a SISC Subscriber's health insurance premium

---

Life Insurance Beneficiary Change Form
File Size:	56 kb
File Type:	pdf

Download File

---

Basic Life Insurance
File Size:	95 kb
File Type:	pdf

Download File

---

Proof of Death Claim Form
File Size:	152 kb
File Type:	pdf

Download File

---

Basic Life Insurance - Conversion Form (to take the policy with you when you leave the District)
File Size:	100 kb
File Type:	pdf

Download File

---

Summary of Basic Life Insurance Coverage - Classified
File Size:	27 kb
File Type:	pdf

Download File

---

Summary of Basic Life Insurance Coverage - Certificated
File Size:	27 kb
File Type:	pdf

Download File

---

Summary of Basic Life Insurance Coverage - Confidential/Management
File Size:	27 kb
File Type:	pdf

Download File

---

---

Voluntary Life Insurance
Additional coverage eligible employees elect with a voluntary payroll deduction

Life Insurance Beneficiary Change Form
File Size:	56 kb
File Type:	pdf

Download File

---

Voluntary Life Insurance - Portability (to take the policy with you when you leave the District)
File Size:	68 kb
File Type:	pdf

Download File

---

Voluntary Term Life Insurance - Enrollment Form
File Size:	123 kb
File Type:	pdf

Download File

---

Voluntary Life Insurance - Evidence of Insurability
File Size:	250 kb
File Type:	pdf

Download File

---

---

Domestic Partner Dependents

Affidavit to Add a Domestic Partner
File Size:	33 kb
File Type:	pdf

Download File

---

Domestic Partner Enrollment Guidelines (AB 205 and non-AB 205)
File Size:	90 kb
File Type:	pdf

Download File

---

---

Preventative Care Totally Covered by Anthem
File Size:	243 kb
File Type:	pdf

Download File

---

Wellness 

Ukiah Area Health Club & Fitness Center Discounts
File Size:	71 kb
File Type:	pdf

Download File

---

Ukiah Area Wellness Resources
File Size:	589 kb
File Type:	pdf

Download File

---

Solera 4 Me: Diabetes Prevention Program
File Size:	595 kb
File Type:	pdf

Download File

---

Ukiah Area Addiction Resources
File Size:	90 kb
File Type:	pdf

Download File

---