West Jordan Utah Form 5020 2025

West Jordan Utah Form 5020: What You Should Know

If you use this form to file a claim regarding your own personal health, you MUST do so in the  off-site health clinic and pay the employee health cover, unless the form is submitted in someone else's name. The City of West Jordan is not responsible for any claims that you file against  West Jordan City if you are not satisfied with the quality of the services provided by staff in the City's City-sponsored  and operated services; they are required to treat all claims on a case-by- case basis. You must have at least a  300 deductible with respect to your claim to be reimbursed for these services. The City makes reasonable efforts to provide assistance  during times of emergency. In the event that the City's health department or a private health organization is unable to provide a satisfactory treatment to you, we may require you to  provide documentation of the treatment you received. In the event that you are unable to file a claim, we may deny your claim and  recover your reasonable out-of-pocket expenses, if any, related to the claims process. Contact the City of West Jordan at ext. 2123, or at the West Jordan City Health Department City of West Jordan Water • City-operated Services • Public Works Services • Human Resources West Jordan Municipal Utilities Department • Customer Service West Jordan Municipal Utilities Department, City of West Jordan, Utah 84084 City of West Jordan Water • City-operated Services • Public Works Services P.O. Box 4979 • West Jordan City, UT 84084 • City of West Jordan Water • City-operated Services • Public Works Services P.O. Box 4979 • West Jordan City, UT 84084 • City of West Jordan Water • City-operated Services • Public Works Services West Jordan Municipal Utilities Department • Customer Service West Jordan Municipal Utilities Department, City of West Jordan, Utah 84084 • SOURCE. ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of your personal health information. If you provide us with your identity or • STATE.

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