Medical Forms

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Prescription Forms

Dental Forms

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

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

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

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

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

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

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

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

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Vision Forms






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Employee Assistance Program (EAP) 

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

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

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

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

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

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

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

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Life Insurance Claim Form
File Size:	298 kb
File Type:	pdf

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Life Insurance Conversion Application
File Size:	375 kb
File Type:	pdf

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

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

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

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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

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Life Insurance - Portability (to take the policy with you when you leave the District)
File Size:	102 kb
File Type:	pdf

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

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

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Domestic Partner Dependents

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

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

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

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Wellness 

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

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

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

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

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