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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 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 SELECT Benefits Summary Chart Employee Benefits UT SELECT Benefits Summary Chart 2018-2019
UT Health Network Flyer Employee Benefits UT Health Network Flyer 2018-2019
UT SELECT Medical Plan Guide with Prescription Drug Coverage Employee Benefits 2018-2019 UT SELECT Benefits Guide
UT CONNECT ACO Benefits Summary Chart Employee Benefits UT CONNECT ACO Benefits Summary Chart 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
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 Conversion Kit Employee Benefits LTD Conversion Kit
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 Care
Document Office Publish Date File
Long-Term Care Highlights Employee Benefits LTC Highlights
Long-Term Care Benefits Guide Employee Benefits ltcguide.pdf
Long-Term Care Outline of Coverage Employee Benefits LTC Outline of Coverage
Special Notices
Document Office Publish Date File
HIPAA Request for Restriction on Use or Disclosure of Protected Health Information Employee Benefits HIPAA Request for Restriction Form
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
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
TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program and/or Refund) Employee Benefits TRS Form 28
Voluntary Retirement Programs Loan and Hardship Options Employee Benefits Voluntary Retirement Programs Loan and Hardship Options
DCP Purchase Agreement Employee Benefits DCP Purchase Agreement
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
Annual Eligibility Notice for Retirement Plans Employee Benefits Annual Eligibility Notice for Retirement Plans
Overview of TRS and ORP Employee Benefits TRS and ORP Overview - July 2019