Forms

EPISD Employee Benefits

• Change of Beneficiary Form

EPISD Health Care Trust Medical Plan Forms

• EPISD Healthcare Plan Enrollment Form T
• Lifestyle Reimbursement Program Application Form
• Lifestyle Reimbursement Program Attendance Log
• Section 125 Enrollment Form

EPISD Health Resource Center

• Eastside Clinic
• Health Clinic Schedules
• Patient Registration Form
• Procedures

Flexible Benefit Plan Forms

• Flexible Benefit Plan Claim Form
• Flexible Benefit Plan Claim Form - Medical
• Flexible Benefit Plan Dependent Care Claim Form

Health Savings Account Categories

• HSA Document
• HSA Enrollment Change Form

ING Life Insurance Forms

• Evidence of Insurability Form
• ING Death Benefits Claim Form
• W-9 ING Form

Leave Management Forms

• CSLB Request Form
• Catastrophic Sick Leave Bank (CSLB) Enrollment Form
• Certification of Health Care Provider
• Certification of Health Care Provider for Family Member
• FMLA Rights & Responsibilities
• FMLA Rights & Responsibilities-Spanish
• Family Medical Leave (FMLA) Request Form
• Leave Comparison Chart

UNUM Disability Forms

• Disability Claim Form
• Medical Treatment Claim Form