Forms and Publications

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    Medical
    Document Office Publish Date File
    UT SELECT Medical Claim Form Employee Benefits UT SELECT Medical Claim Form
    UT SELECT Tobacco Cessation Program Employee Benefits UT SELECT Tobacco Cessation Program
    UT SELECT Weight Management Program Employee Benefits Weight Management Program
    24/7 Nurseline Employee Benefits 24/7 Nurseline
    PPO Network Summary of Benefits and Coverage Employee Benefits 2018-2019 Summary of Benefits Summary: PPO Plan
    2018-2019 Summary of Benefits Summary: PPO Plan (Spanish/Español)
    2019-2020 Summary of Benefits: PPO Plan
    Out-of-Area Network Summary of Benefits and Coverage Employee Benefits 2019-2020 Summary of Benefits: Out-of-Area Plan
    2018-2019 Summary of Benefits and Coverage: Out-of-Area Plan
    2018-2019 Summary of Benefits and Coverage: Out-of-Area Plan (Spanish/Español)
    Glossary of Health Coverage and Medical Terms Employee Benefits Glossary of Health Coverage and Medical Terms
    UT Health Network Flyer Employee Benefits UT Health Network Flyer 2018-2019
    Tobacco Premium Program Declaration Form Employee Benefits Tobacco Premium Program Declaration Form
    Physician Statement Concerning Tobacco Usage and Fitness to Participate in a Tobacco Cessation Program Employee Benefits Tobacco Cessation Program Physician Statement
    UT CONNECT ACO Medical Plan FAQs Employee Benefits UT CONNECT FAQs 2019-2020
    UT SELECT Medical Plan Guide with Prescription Drug Coverage Employee Benefits
    UT CONNECT ACO Benefits Summary Chart Employee Benefits UT CONNECT ACO Benefits Summary Chart 2019-2020
    UT CONNECT ACO Benefits Summary Chart 2018-2019
    UT SELECT Benefits Summary Chart Employee Benefits UT SELECT Benefits Summary Chart 2019-2020
    UT SELECT Benefits Summary Chart 2018-2019
    Pharmacy
    Document Office Publish Date File
    Prescription Drug Co-payments at a Glance Employee Benefits Prescription Drug Copayments at a Glance
    Prescription Drug Reimbursement Form / Coordination of Benefits Claim Form Employee Benefits Prescription Drug Reimbursement Form / Coordination of Benefits Claim Form
    UT SELECT Part D Mail Order Form UT SELECT Part D Mail Order Form
    UT SELECT Part D Contacts UT SELECT Part D Contacts
    UT SELECT Part D Presentation UT SELECT Part D Presentation
    UT SELECT Part D Welcome Kit Letter Employee Benefits UT SELECT Part D Welcome Kit Letter
    UT SELECT Part D Evidence of Coverage UT SELECT Part D Evidence of Coverage
    UT SELECT Part D Language Services UT SELECT Part D Language Services
    Prescriptions by Mail Order Form Employee Benefits Prescriptions by Mail Order Form
    Dental
    Document Office Publish Date File
    DeltaCare Highlights Employee Benefits DeltaCare Highlights
    Delta Dental Online Services Employee Benefits Delta Dental Online Services
    UT SELECT DENTAL Claim Form Employee Benefits UT SELECT DENTAL Claim Form
    SmileWaySM Wellness Program: Take the Challenge Employee Benefits SmileWaySM Wellness Program
    UT SELECT DENTAL Highlights Employee Benefits UT SELECT DENTAL Highlights
    DeltaCare - Getting the Most from Your Dental HMO Employee Benefits Getting the Most from Your Dental HMO
    Recommend Your Dentist Employee Benefits Recommend Your Dentist
    UT SELECT DENTAL Plus Highlights Employee Benefits UT SELECT DENTAL Plus Highlights
    Your Dental Plan Options Employee Benefits Dental Plan Options
    UT SELECT DENTAL - Getting the Most from Your DPO Network Employee Benefits Getting the Most from Your DPO Network
    The Connection Between Your Oral and Overall Health Employee Benefits Your Oral and Overall Health
    UT SELECT DENTAL Benefits Guide Employee Benefits UT SELECT DENTAL Benefits Guide 2019-2020
    UT SELECT DENTAL Benefits Guide 2018-2019
    UT SELECT DENTAL Plus Benefits Guide Employee Benefits UT SELECT DENTAL Plus Benefits Guide 2019-2020
    UT SELECT DENTAL Plus Benefits Guide 2018-2019
    DeltaCare Benefits Guide Employee Benefits DeltaCare Benefits Guide
    Vision
    Document Office Publish Date File
    Superior Vison Claim Form Employee Benefits Superior Vison Claim Form
    Smart Alert - Partnering for Total Wellness Employee Benefits Superior Vision Smart Alert
    Finding-In-Network Providers Employee Benefits Finding-In-Network Providers
    Getting Started with the Online Member Portal Employee Benefits Superior Vision Online Member Portal
    SVContacts.com - Online Contact Lens Ordering Employee Benefits Online Contact Lens Ordering
    Superior Vision Plan Brochure Employee Benefits Superior Vision Plan Brochure
    Quality LASIK for Texas Members Employee Benefits Quality LASIK for Texas Members
    Superior Vision Standard Benefits Guide Employee Benefits Superior Vision Basic Plan Certificate
    Superior Vision Plan Amendment (eff. 9/1/2017)
    Superior Vision Plus Benefits Guide Employee Benefits Superior Vision Plus Plan Certificate
    Superior Vision Plan Amendment (eff. 9/1/2017)
    Superior Vision Plan Highlights Employee Benefits Superior Vision Highlights
    Flexible Spending Accounts
    Document Office Publish Date File
    UT FLEX Letter of Medical Necessity Form Employee Benefits Letter of Medical Necessity
    UT FLEX Health Care Reimbursement Claim Form Employee Benefits UT FLEX HCRA Claim Form
    UT FLEX Dependent Care Reimbursement Claim Form Employee Benefits UT FLEX DCRA Claim Form
    UT FLEX Benefits Guide Employee Benefits UT FLEX Benefits Guide 2019-2020
    UT FLEX Benefits Guide 2018-2019
    Life and Accidental Death and Dismemberment (AD&D)
    Document Office Publish Date File
    Life Portability Application Employee Benefits Life Portability Application
    Beneficiary Designation Form Employee Benefits Beneficiary Designation Form
    Accelerated Death Claim Form Employee Benefits Accelerated Death Claim Form
    Life Conversion Application Employee Benefits Application to Convert Group Life Insurance
    About Online Beneficiary Management Employee Benefits Online Beneficiary Management
    Death Claim Form Employee Benefits Death Claim Form
    Create Your Own Will Online Employee Benefits Create Your Own Will Online
    Portability and Conversion of Life Insurance Employee Benefits Portability and Conversion of Life Insurance
    Accidental Dismemberment Claim Form Employee Benefits Accidental Dismemberment Claim Form
    Group Term Life Benefits Guide Employee Benefits Group Term Life Benefits Guide
    Accidental Death & Dismemberment Benefits Guide Employee Benefits Accidental Death & Dismemberment Benefits Guide
    Life Benefit Highlights for Retired Employees Employee Benefits Life Benefit Highlights for Retired Employees
    Life/AD&D Benefit Highlights for Active Employees Employee Benefits Life/AD&D Benefit Highlights for Active Employees
    Short-Term Disability (STD)
    Document Office Publish Date File
    STD Integrated Medical/Disability STD Integrated Medical/Disability
    Short-Term Disability Benefits Guide Employee Benefits Short Term Disability Guide
    Filing Your STD Claim Employee Benefits Filing Your STD Claim
    STD Benefit Highlights Employee Benefits STD Benefit Highlights
    Long-Term Disability (LTD)
    Document Office Publish Date File
    LTD Conversion Calculator Employee Benefits LTD Conversion Calculator
    LTD Employee Claim Form Employee Benefits LTD Employee Claim Form
    Long-Term Disability Benefits Guide Employee Benefits Long Term Disability Guide
    LTD Employer Claim Form Employee Benefits LTD Employer Claim Form
    Long-Term Disability Benefit Highlights Employee Benefits ltd-benefit-highlights-2017.pdf
    Long-Term Disability Conversion Kit Employee Benefits Long-Term Disability Conversion Kit
    Long-Term Care
    Document Office Publish Date File
    Long-Term Care Benefits Guide Employee Benefits ltcguide.pdf
    Long-Term Care Outline of Coverage Employee Benefits LTC Outline of Coverage
    Long-Term Care Highlights Employee Benefits LTC Highlights
    Special Notices
    Document Office Publish Date File
    HIPAA Breach Log Employee Benefits HIPAA Breach Log
    HIPAA Request for Confidential Communications of Medical Information Employee Benefits HIPAA Request for Confidential Communications of Medical Information Form
    HIPAA Request for Amendment of Protected Health Information Employee Benefits HIPAA Request for Amendment of Protected Health Information Form
    HIPAA Request for Restriction on Use or Disclosure of Protected Health Information Employee Benefits HIPAA Request for Restriction Form
    Notice of Creditable Coverage (NOCC) Employee Benefits Medicare Part D Notice of Creditable Coverage
    HIPAA General Authorization Form Employee Benefits HIPAA General Authorization Form
    HIPAA Request for Access to Protected Health Information Employee Benefits Request for Access Form
    HIPAA Revocation of Authorization Employee Benefits HIPAA Revocation of Authorization Form
    HIPAA Request for Accounting of Disclosures Employee Benefits HIPAA Request for Accounting of Disclosues Form
    HIPAA Staff Assistance Authorization Employee Benefits HIPAA Staff Assistance Authorization
    HIPAA Complaint Form Employee Benefits HIPAA Complaint Form
    BAC By-Laws Employee Benefits BAC By-laws
    Nondiscrimination and Accessibility Notice Employee Benefits Nondiscrimination and Accessibility Notice
    Affordable Care Act - Marketplace Notices Employee Benefits UT Arlington ACA Notice
    UT Austin ACA Notice
    UT Dallas ACA Notice
    UT El Paso ACA Notice
    UT Health Houston ACA Notice
    UT Health San Antonio ACA Notice
    UT Health Northeast ACA Notice
    UT Medical Branch Galveston ACA Notice
    UT MD Anderson Cancer Center ACA Notice
    UT Permian Basin ACA Notice
    UT Rio Grande Valley ACA Notice
    UT San Antonio ACA Notice
    UT Southwestern Medical Center ACA Notice
    UT System Administration ACA Notice
    UT Tyler ACA Notice
    Medicaid and the Children's Health Insurance Program (CHIP) Notice Employee Benefits Medicaid and the Children's Health Insurance Program (CHIP) Notice
    Legal Notices Employee Benefits UT Benefits - Legal Notices 2019
    UT Benefits - Legal Notices 2018
    UT Retirement Program
    Document Office Publish Date File
    UTSaver TSA Disclosure Form Employee Benefits UTSaver TSA Disclosure Form
    ORP Authorization for Reduction for Employee Contribution Employee Benefits ORP Authorization for Reduction for Employee Contribution
    DCP Catch-Up Provision Agreement Employee Benefits DCP Catch-Up Provision Agreement
    Purchase Change Agreement (All plans) Employee Benefits UT Retirement Purchase Change Agreement (All plans)
    ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE Employee Benefits ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE
    UT Transfer Verification Form (All plans) Employee Benefits UT Transfer Verification Form (All plans)
    Vendor Services Employee Benefits Vendor Services for Retirement Participants
    ORP Acknowledgement Employee Benefits ORP Acknowledgement
    Vesting/Termination Status Form Employee Benefits Vesting/Termination Status Form
    DCP Purchase Agreement Employee Benefits DCP Purchase Agreement
    Overview of TRS and ORP Employee Benefits TRS and ORP Overview - July 2019
    TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program and/or Refund) Employee Benefits TRS Form 28
    Comparison of Traditional, Roth 403(b), and Roth IRA Contributions Employee Benefits Comparison of Traditional, Roth 403(b), and Roth IRA Contributions
    Summary of Retirement Programs Employee Benefits Retirement Programs Summary
    Voluntary Retirement Programs At a Glance Employee Benefits Voluntary Retirement Programs
    Voluntary Retirement Programs Loan and Hardship Options Employee Benefits Voluntary Retirement Programs Loan and Hardship Options
    Annual Eligibility Notice for Retirement Plans Employee Benefits Annual Eligibility Notice for Retirement Plans
    UT Benefits Billing
    Document Office Publish Date File
    Helpful Hints for Completing the Direct Payment Agreement Employee Benefits Helpful Hints for Completing the Direct Payment Agreement
    UT Benefits Billing Reference Guide Employee Benefits UT Benefits Billing Reference Guide
    UT Benefits Billing Direct Payment/Debit Authorization Agreement Employee Benefits Direct Payment/Debit Authorization Agreement
    UT Benefits Billing for COBRA Direct Payment/Debit Authorization Agreement Employee Benefits UT Benefits Billing for COBRA Direct Payment/Debit Authorization Agreement
    Personal Information and Emergency Contact Form Employee Benefits Personal Information and Emergency Contact Form
    Benefits Handbooks and Cost Worksheet
    Document Office Publish Date File
    Benefits Cost Worksheet for Retired Employees Employee Benefits NEW! 2019-2020 Retired Employee Cost Worksheet
    2018-2019 Retired Employee Cost Worksheet
    Annual Enrollment & Resource Guide for Retired Employees Employee Benefits NEW! 2019-2020 Annual Enrollment & Resource Guide for Retired Employees
    2018-2019 Annual Enrollment & Resource Guide for Retired Employees
    Benefits Cost Worksheet for Employees Employee Benefits NEW! 2019-2020 Active Employee Cost Worksheet
    2018-2019 Active Employee Cost Worksheet
    Annual Enrollment & Resource Guide for Employees Employee Benefits NEW! 2019-2020 Annual Enrollment & Resource Guide for Employees
    2018-2019 Annual Enrollment & Resource Guide for Employees
    UT Benefits Enrollment Guide for Employees Employee Benefits UT Benefits Enrollment Guide for Employees 2019-2020
    UT Benefits Enrollment Guide for Employees 2018-2019
    UT Benefits Enrollment Guide for Retiring Employees Employee Benefits UT Benefits Enrollment Guide for Retiring Employees 2019-2020
    UT Benefits Enrollment Guide for Retiring Employees 2018-2019
    Other
    Document Office Publish Date File
    Grandchild Certification Form Employee Benefits Grandchild Certification Form
    UT System Cafeteria Plan Document Employee Benefits UT System Cafeteria Plan Document
    International Travel Quick Reference Sheet Employee Benefits ut-system-foreign-coverage-quick-reference-sheet-12-2016.pdf
    COBRA General Notice Employee Benefits COBRA General Notice for the 2017-2018 Plan Year
    COBRA General Notice for the 2018-2019 Plan Year
    COBRA Application FAQs Employee Benefits COBRA Application FAQs
    COBRA Rates Employee Benefits COBRA Rates 2019-2020
    COBRA Rates 2018-2019
    Office of Employee Benefits Organizational Chart Employee Benefits Office of Employee Benefits Organizational Chart
    Retirement Plan Documents
    Document Office Publish Date File
    Optional Retirement Program (ORP) Plan Document Employee Benefits Optional Retirement Program (ORP) Plan Document
    UTSaver DCP - 457(b) Plan Document Employee Benefits UTSaver DCP - 457(b) Plan Document
    UTSaver TSA - 403(b) Plan Document Employee Benefits UTSaver TSA - 403(b) Plan Document
    UT Retirement Provider Agent Listing Employee Benefits UT Retirement Provider Agent Listing