Forms

Health & Well-Being Forms

HDHP and PPO Options

• Aetna Medical Claim Form
• Aetna Transition of Care Form
• BCBS Medical Claim Form
• BCBS Transition of Care Form

Prescription Drugs (for HDHP and PPO options only)

• Prescription Drug Mail Order Form
• Prescription Drug Reimbursement Form
• Prior Authorization Form

Qualified Domestic Relations Orders (QDROs) and Qualified Medical Child Support Orders (QMCSOs)

• Qualified Domestic Relations Orders (QDROs) and Qualified Medical Child Support Orders (QMCSOs) Qualified Order Center (complete the QDRO and QMCSO processes here)

Dental Option

• MetLife Dental Claim Forms (located under "Forms at Your Fingertips”)

Vision Option

• VSP Member Reimbursement Form

Total Well-Being Incentive Program and Reimbursement Account

• Total Well-Being Incentive Program FAQ
• Total Well-Being Reimbursement Account FAQ
• Smart Choice User Guide (step-by-step claims instructions)

Flexible Spending Plan

Forms can be accessed online through Upoint in two ways:

• Go to My HR Tools, click on the Health & Well-Being card, select UPoint, then click on the Flexible Spending Account tile
• From your computer or mobile device: Go to digital.alight.com/phillips66, enter your UPoint user ID and password, then click on the Flexible Spending Account tile.

Short-Term Disability (STD)

• Employee Health Report
• Employee Health Report Supplement
  • Employee Rights Under FMLA

Expatriate Inpatriate and NCNR Health Care Benefits

• Cigna International Claim Form

Retiree Medical

• Aetna Medical Claim Forms
• BCBS Medical Claim Form
• Prescription Drug Mail Order Form
• Prescription Drug Reimbursement Form
• Prior Authorization Form

Compensation

Phillips 66 Equity Programs

• Stock Option Attestation Form

Savings Forms

Phillips 66 Savings Plan

• Savings Plan Forms at Vanguard (located on the participant’s account under Plan Details)

Employment, Payroll and LOA Forms

Severance Pay Plan

• Educational Reimbursement Application

Employment and Payroll Forms

• Update your direct deposit information on My HR Tools
• Update your Race/Ethnicity, Gender and Veteran Status on My HR Tools

Leave of Absence Forms

• Employee Health Report
  • Employee Rights Under FMLA
• Employee Health Report Supplement
  • Employee Rights Under FMLA
• Certification of Health Care Provider for Employee’s Serious Health Condition
• Certification of Health Care Provider for Family Member’s Serious Health Condition
• California Intermittent – Self
• California Intermittent – Family
• Certification for Qualifying Exigency for Military Family Leave
• Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave
• FMLA Request for Bonding and Parental Leave