Publications and Forms

For Plan Year Beginning September 1, 2012

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• UT Benefits Handbook for Employees
• UT Benefits Handbook for Retired Employees
• Benefits Cost Worksheet
• Office of Employee Benefits Administrative Manual

MEDICAL - Blue Cross and Blue Shield of Texas

• UT SELECT Benefits Guide
• UT SELECT Highlights
• UT SELECT Benefits Summary Chart
• Your UT SELECT Health Benefits at a Glance
• Your UT SELECT Health Benefits at a Glance Pocket Guide
• Blue Care Connection Flyer
• Medical Claim Form
• Tobacco Cessation and Weight Management Programs
• Condition Management Programs
• UTSW Network Announcement

PHARMACY - Medco

• UT SELECT Benefits Announcement
• Prescription Drug Copayments at a Glance
• Medco by Mail Order Form
• Prescription Drug Reimbursement Form
• Coordination of Benefits/Direct Claim Form

DENTAL - Delta Dental

• Your Dental Plan Options
• UT SELECT DENTAL Benefits Guide
• DeltaCare Benefits Guide
• UT SELECT DENTAL Claim Form
• UT SELECT DENTAL Highlights
• UT SELECT DENTAL Plus Highlights
• Getting the Most from Your DPO Network
• DeltaCare Highlights
• DeltaCare - Getting the Most from Your Dental HMO
• DeltaCare Continuous Orthodontic Coverage Form
• Delta Dental Online services
• Recommend Your Dentist
• The connection between your oral and overall health
• SmileWaySM Wellness Program: Take the Challenge

VISION - Superior Vision

• Superior Vision Benefits Guide (Available soon)
• Superior Vision Benefits Brochure
• Superior Vision's New Plus Plan Highlights
• Provider Nomination Form
• Superior Vison Claim Form
• Getting Started with the Online Member Portal
• Smart Alert - Partnering for Total Wellness
• SVContacts.com - Online Contact Lens Ordering
• Finding-In-Network Providers
• Quality LASIK for Texas Members

UT FLEX - PayFlex Systems

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

LIFE & ACCIDENTAL DEATH and DISMEMBERMENT(AD&D) Dearborn National

• Group Term Life Benefits Guide
• Accidental Death & Dismemberment Benefits Guide
• Life/AD&D Benefit Highlights for Active Employees
• Portability and Conversion of Life Insurance
• Life Conversion Application
• Life Portability Application
• Death Claim Form
• Accelerated Death Claim Form
• Waiver of Premium Claim Form
• Accidental Dismemberment Claim Form
• About Online Beneficiary Management
• Beneficiary Designation Form
• AD&D Enhancements
• Create Your Own Will Online

SHORT TERM DISABILITY (STD) - Dearborn National

• Short Term Disability Benefits Guide
• Short Term Disability Highlights
• Blue Care Link
• Filing Your STD Claim

LONG TERM DISABILITY (LTD) - Dearborn National

• Long Term Disability Benefits Guide
• Long Term Disability Benefit Highlights
• LTD Employee Claim Form
• LTD Employer Claim Form
• LTD Conversion Kit
• LTD Conversion Calculator

LONG TERM CARE (LTC) - CNA

• Long Term Care Guide
• Long Term Care Highlights
• LTC Enrollment Form for new employees
• LTC Short Form Application for current employees and spouses
• LTC Long Form Application for all other applicants
• Why You Should Consider Long Term Care
• Introducing Long Term Care

RETIREMENT

• Summary of Retirement Programs
• Overview of TRS and ORP
• Optional Retirement Program (ORP) Plan Document
• ORP Acknowledgement
• ORP Authorization for Reduction for Employee Contribution
• ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE
• TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program and/or Refund)
• Vesting/Termination Status Form
• Voluntary Retirement Programs At a Glance
• Voluntary Retirement Programs Loan and Hardship Options
• Voluntary Retirement Programs Transfer Verification Form
• UTSaver TSA - 403(b) Plan Document
• Purchase/Change form for TSA (Traditional  or Roth)-ORP changes
• Comparison of Traditional, Roth 403(b), and Roth IRA Contributions
• UTSaver DCP - 457(b) Plan Document
• DCP Catch-Up Provision Agreement
• DCP Purchase Agreement

SPECIAL NOTICES

• Early Retiree Reinsurance Program (ERRP) Notice and Q&As
• Notice of Creditable Coverage (NOCC)
• HIPAA Notice of Privacy Policies and Procedures
• Medicaid and the Children's Health Insurance Program (CHIP) Notice

OTHER

• Chapter 1601 of the Texas Insurance Code
  
• HIPAA Privacy Information
  
• HIPAA Security of Electronic Protected Health Information (PHI) COMPLIANCE MANUAL
• UT System Cafeteria Plan Document