Publications and Forms

 

Benefits Guides - Detailed information about the benefits you are entitled to and the provisions of the insurance plans

Group Benefits Handbook for Employees

Group Benefits Handbook for Retired Employees

Office of Employee Benefits Administrative Manual

MEDICAL - Blue Cross and Blue Shield of Texas

• UT SELECT Benefits Summary Chart
• UT SELECT Benefits Guide
• UT SELECT Health Benefits at a Glance
• Medical Claim Form
• Wellness Benefits
• Tobacco Cessation
• Weight Management
• Prescription Program at a Glance Medco Health
• Medco by Mail Order Form Medco Health
• Prescription Claim Form Medco Health

DENTAL

• Assurant Dental HMO Benefits Guide Assurant Employee Benefits
• Assurant Dental Evidence of Coverage Assurant Employee Benefits
• UT SELECT DENTAL Benefits Guide Delta Dental
• UT SELECT DENTAL Claim Form Delta Dental
• UT SELECT DENTAL Brochure Delta Dental
• Finding a Dentist Delta Dental
• Your Plan and the DPO Network Delta Dental

VISION - Superior Vision

• Superior Vision Benefits Guide
• Superior Vision Benefits Summary
• Provider Nomination Form
• Superior Vision Brochure
• Getting Started with the Online Member Portal
• Smart Alert - Partnering for Total Wellness
• SVContacts.com - Online Contact Lens Ordering

UT FLEX - PayFlex Systems

• UT FLEX Benefits Guide
• UT FLEX Claim Form
• Direct Deposit Authorization Form
• Letter of Medical Necessity Form
• The PayFlex Debit Card
• Flexible Spending Accounts (FSA) Brochure

LIFE & ACCIDENTAL DEATH and DISMEMBERMENT(AD&D) Fort Dearborn Life

• Group Term Life Benefits Guide
• Accidental Death & Dismemberment Benefits Guide
• Life/AD&D Brochure
• Beneficiary Designation Form

SHORT TERM DISABILITY (STD) - The Hartford

• Short Term Disability Benefits Guide
• Short Term Disability Highlights
• Worldwide Travel Assistance

LONG TERM DISABILITY (LTD) - The Hartford

• Long Term Disability Benefits Guide
• Long Term Disability Highlights
• Long Term Disability Assist
• Worldwide Travel Assistance

LONG TERM CARE (LTC) - CNA

• Long Term Care Guide
• Long Term Care Highlights
• Why Should You Consider Long Term Care
• Introducing Long Term Care

Other

• Benefits Cost Worksheet
  
• Transitional Benefits Form
  
• Change In Status Form For Mid-Year Benefit Election Changes
  
• Chapter 1601 of the Texas Insurance Code
  
• Coverage For Incapacitated Child Form
• Optional Retirement Program (ORP) Certification Form
  
• Office of Employee Benefits Organizational Chart
  
• HIPAA Privacy Information
  
• HIPAA Security of Electronic Protected Health Information (PHI) COMPLIANCE MANUAL