Forms and Publications

For the 2007-2008 Plan Year

Benefits Library for HR staff only

Benefits Guides

View all Benefits Guides containing detailed information about the benefits you are entitled to and the provisions of the insurance plans.

Policies

Office of Employee Benefits Administrative Manual

Employees

Group Benefits Handbook for Employees
Optional Retirement Program (ORP) Certification Form

Retirees

Group Benefits Handbook for Retired Employees
Notice of Creditable Coverage for Medicare Part D

Medical

UT SELECT Summary Chart
UT SELECT Benefits Guide  - BlueCross BlueShield of Texas
U T SELECT Enrollment Guide  - BlueCross BlueShield of Texas
UT SELECT Quick Reference Guide - BlueCross BlueShield of Texas
Medical Claim Form - BlueCross BlueShield of Texas
UT SELECT Home Delivery Service Form - Medco Health
UT SELECT Prescription Claim Form - Medco Health

Dental

Assurant Dental HMO Benefit 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

Vision

Superior Vision Benefits Guide
Superior Vision Benefits Summary
Superior Vision Provider Nomination Form
Superior Vision Brochure

U T FLEX

U T FLEX Benefits Guide  - PayFlex Systems
PayFlex Direct Deposit Authorization Form  - PayFlex Systems
PayFlex Give Yourself A Pay Raise! Brochure  - PayFlex Systems
PayFlex Letter of Medical Necessity Form  - PayFlex Systems
UT FLEX Claim Form  - PayFlex Systems

Life & Accidental Death and Dismemberment (AD&D)

Group Term Life Benefits Guide - Fort Dearborn Life
Accidental Death & Dismemberment Benefits Guide - Fort Dearborn Life
Fort Dearborn Life / PAI Brochure  - Fort Dearborn Life Insurance
Fort Dearborn Life Beneficiary Designation Form  - Fort Dearborn Life Insurance

Short Term and Long Term Disability

Long Term Disability Benefits Guide - Hartford
Short Term Disability Benefits Guide - Hartford
Short Term Disability FAQs - Hartford
Worldwide Travel Assistance

Long Term Care

Long Term Care Guide - CNA
Long Term Care Highlights - CNA
Why Should You Consider Long Term Care Flyer - CNA

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
Office of Employee Benefits Organizational Chart
HIPAA Privacy Information
HIPAA Security of Electronic Protected Health Information (PHI) COMPLIANCE MANUAL