Forms

		Health Plan TRS-ActiveCare New Employees Plan Descriptions Find a Network Provider Forms Filing a Claim Employee Assistance Program Changing Benefits Pre-Existing Condition Limitation Part-Time Benefits COBRA HIPAA Flexible Benefit Program Plan Documents

Click here for "Claim Forms and Instructions"

Flexible Spending Account:

• Request for 1) Additional Flex Card, 2) Direct Deposit Claim Reimbursement, and/or 3) E-mail Communications (20 KB)
• Flex Card Transaction Substantiation Form (417 KB)
• How to Use Your Flex Card (740 KB)

Medco Prescriptions:

• Medco Mail-Order Prescription Form (110 KB)
• Medco Retail Prescription Reimbursement Form (50 KB) - Use this form to be reimbursed for a retail prescription you paid for in full.
• Medco - Health, Allergy & Medication Questionnaire (48 KB)

Cancel Life Insurance (10 KB) - Life insurance may be canceled anytime. Return completed form to the PISD Benefits department.

Life Insurance - SunLife

• Application Form (290 KB)
  • Return completed form to the PISD Benefits department.
• Online health questionnaire
  • Click on Evidence of Insurability Application, follow the instructions, review your answers, and sign your application electronically before you submit.
• Everyone requesting life insurance must complete the health questionnaire, EXCEPT new employees who are enrolling within 31 days from their hire date and are requesting $250,000 or less.
• Beneficiary Change Form
  • Return completed form to the PISD Benefits department.

Disability Insurance:

• Online Enrollment Request - Only available for new employees at this time. Refer to printed enrollment materials for login instructions.
• Disability Plan Rates:
  7/7 elimination period (36 KB)
  14/14 elimination period (36 KB)
  30/30 elimination period (36 KB)
  90/90 elimination period (36 KB)

TRS-ActiveCare Forms:

Application to Split Premium (188 KB) - Use this form ONLY if you and your spouse work for different school districts and you qualify to split the family premium. Do not use this form if you and your spouse both work for PISD.

Dependent Child's Statement of Disability (182 KB) - Use this form if you will be requesting TRS-ActiveCare medical coverage for a disabled child over age 25.

Transitional Care Request Form (171 KB) - Use this form if you will be using a non-network doctor under TRS-ActiveCare. The criteria to qualify for transitional care are explained in the TRS Benefits Booklet on page 38.