Forms and Publications

Insurance Benefits List | Retirement Programs List

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Insurance Benefits

Guides and Policies

• 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 / PHARMACY - Medco

• Prescription Program at a Glance
• Medco by Mail Order Form
• Prescription Claim Form
• Temporary Prescription Card
• Coordination of Benefits / Direct Claim Form

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
  
• 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

Retirement Programs

Optional Retirement Program

• ORP Plan
• Transfer Verification Form - Use to transfer balances from one provider to another
• TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program) - The TRS 28 must be completed by all participants making their initial ORP election.
• TRS Form 29 (Application for Refund) - Use only if you have an account balance with TRS

UTSaver Tax-Sheltered Annuity Program

• UTSaver TSA Plan
• Loan, Hardship and Unforseeable Emergency Procedures
• Transfer Verification Form - Use to transfer balances from one provider to another

UTSaver Deferred Compensation Plan

• Purchase Agreement for Annual Leave Deferral
• UTSaver DCP Policy
• Loan, Hardship and Unforseeable Emergency Procedures
• Transfer Verification Form - Use to transfer balances from one provider to another.
• Special Catch-Up Provision Disclosure - This must be signed if utilizing the Special Catch-Up Provision and must be accompanied by a calculation sheet.

Forms to download if you do not wish to use UTRetirement Manager

If you are making an initial ORP election, you must also complete the TRS 28 form listed at the top of this page.

• Purchase/Change Agreement - Use to change provider(s) for future retirement contributions
• Authorization for Reduction for Employee Contribution - Use for initial ORP election
• Authorization for Reduction for Employee Contribution for Employees Returning to ORP - Use for ORP election for vested participants returning to employment
• ORP Acknowledgement Form - Must be signed by all employees who are newly-eligible for ORP
• Tax-Sheltered Annuity Disclosure - This must be signed before your enrollment into a TSA is effective

Your Benefits Office can help you complete these forms.