Forms and Publications | University of Texas System

Forms and Publications

Forms and Publications

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Benefits Materials and Cost Worksheets
Medical
Pharmacy
Dental
Vision
Flexible Spending Accounts
Life and Accidental Death and Dismemberment (AD&D)

Short-Term Disability (STD)
Long-Term Disability (LTD)
Long-Term Care
Special Notices
Other
UT Retirement Program
UT Benefits Billing

Benefits Handbooks and Cost Worksheet

UT Benefits Enrollment Guide for Employees 2016-2017	UT Benefits Enrollment Guide for Employees 2016-2017
Annual Enrollment & Resource Guide for Retired Employees 2016-2017	Annual Enrollment & Resource Guide for Retired Employees 2016-2017
Benefits Overview for Retired Employees 2016-2017	Benefits Overview for Retired Employees 2016-2017
Annual Enrollment & Resource Guide for Employees 2016-2017	Annual Enrollment & Resource Guide for Employees 2016-2017
Benefits Cost Worksheet for Employee 2016-2017	Benefits Cost Worksheet for Employee 2016-2017
Benefits Cost Worksheet for Retired Employee 2016-2017	Benefits Cost Worksheet for Retired Employee 2016-2017
Benefits Overview for Employees 2016-2017	Benefits Overview for Employees 2016-2017
UT Benefits Enrollment Guide for Retired Employees 2015-2016	UT Benefits Enrollment Guide for Retired Employees 2015-2016

Retirement Plan Documents

UTSaver DCP - 457(b) Plan Document	UTSaver DCP - 457(b) Plan Document
UTSaver TSA - 403(b) Plan Document	UTSaver TSA - 403(b) Plan Document
Optional Retirement Program (ORP) Plan Document	Optional Retirement Program (ORP) Plan Document

Medical

UT SELECT Tobacco Cessation Program	UT SELECT Tobacco Cessation Program
UT SELECT Medical Plan Guide with Prescription Drug Coverage	2015-16 UT SELECT Benefits Guide
24/7 Nurseline	24/7 Nurseline
Physician Statement Concerning Tobacco Usage and Fitness to Participate in a Tobacco Cessation Program	Tobacco Cessation Program Physician Statement
UT SELECT Weight Management Program	Weight Management Program
UT SELECT Benefits Summary Chart	UT SELECT Benefits Summary Chart
UT SELECT Highlights	UT SELECT Medical Plan Highlights
Tobacco Premium Program Declaration Form	Tobacco Premium Program Declaration Form
UT SELECT Medical Claim Form	UT SELECT Medical Claim Form

Pharmacy

Prescription Drug Reimbursement Form / Coordination of Benefits Claim Form	Prescription Drug Reimbursement Form / Coordination of Benefits Claim Form
Prescription Drug Co-payments at a Glance	Prescription Drug Copayments at a Glance
Prescriptions by Mail Order Form	Prescription Mail Order Form 2015-2016

Dental

UT SELECT DENTAL Claim Form	UT SELECT DENTAL Claim Form
UT SELECT DENTAL Plus Highlights	UT SELECT DENTAL Plus Highlights
UT SELECT DENTAL Benefits Guide 2016-2017	UT SELECT DENTAL Benefits Guide 2016-2017
SmileWaySM Wellness Program: Take the Challenge	SmileWaySM Wellness Program
Recommend Your Dentist	Recommend Your Dentist
DeltaCare - Getting the Most from Your Dental HMO	Getting the Most from Your Dental HMO
DeltaCare Highlights	DeltaCare Highlights
UT SELECT DENTAL - Getting the Most from Your DPO Network	Getting the Most from Your DPO Network
UT SELECT DENTAL Highlights	UT SELECT DENTAL Highlights
UT SELECT DENTAL Plus Benefits Guide 2016-2017	UT SELECT DENTAL Plus Benefits Guide 2016-2017
Delta Dental Online Services	Delta Dental Online Services
The Connection Between Your Oral and Overall Health	Your Oral and Overall Health
Your Dental Plan Options	Dental Plan Options
DeltaCare Benefits Guide	DeltaCare Benefits Guide

Vision

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

Flexible Spending Accounts

UT FLEX Health Care Reimbursement Claim Form	UT FLEX HCRA Claim Form
UT FLEX Letter of Medical Necessity Form	Letter of Medical Necessity
UT FLEX Benefits Guide
UT FLEX Dependent Care Reimbursement Claim Form	UT FLEX DCRA Claim Form

Life and Accidental Death and Dismemberment (AD&D)

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

Short-Term Disability (STD)

Filing Your STD Claim	Filing Your STD Claim
STD Integrated Medical/Disability	STD Integrated Medical/Disability
STD Benefit Highlights	STD Benefit Highlights
Short-Term Disability Benefits Guide	Short Term Disability Guide

Long-Term Disability (LTD)

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

Long-Term Care

Long-Term Care Benefits Guide	ltcguide.pdf
Long-Term Care Highlights	LTC Highlights
Long-Term Care Outline of Coverage	LTC Outline of Coverage

Special Notices

Medicaid and the Children's Health Insurance Program (CHIP) Notice	Medicaid and CHIP Notice
HIPAA Breach Log	HIPAA Breach Log
HIPAA Revocation of Authorization	HIPAA Revocation of Authorization Form
HIPAA Request for Confidential Communications of Medical Information	HIPAA Request for Confidential Communications of Medical Information Form
HIPAA Request for Accounting of Disclosures	HIPAA Request for Accounting of Disclosures Form
HIPAA Staff Assistance Authorization	HIPAA Staff Assistance Authorization
SWIAC By-Laws	SWIAC By-laws
Legal Notices	UT Benefits - Legal Notices
HIPAA Notice of Privacy Practices	HIPAA Notice of Privacy Practices
HIPAA Complaint Form	HIPAA Complaint Form
HIPAA Request for Restriction on Use or Disclosure of Protected Health Information	HIPAA Request for Restriction Form
HIPAA Request for Amendment of Protected Health Information	HIPAA Request for Amendment of Protected Health Information Form
HIPAA General Authorization Form	HIPAA General Authorization Form
HIPAA Request for Access to Protected Health Information	Request for Access Form
Notice of Creditable Coverage (NOCC)	Medicare Part D Notice of Creditable Coverage

Other

International Travel Quick Reference Sheet	utsystemforeigncoveragequickreferencesheet112014.pdf
Family Secure	Family Secure® Online Credit Monitoring
UT System Cafeteria Plan Document	UT System Cafeteria Plan Document
ProtectMyID	ProtectMyID® – World-Class Identity Protection
COBRA General Notice	COBRA General Notice

UT Retirement Program

Summary of Retirement Programs	Retirement Programs Summary
Overview of TRS and ORP	TRS and ORP Overview - August 2015
UT Transfer Verification Form (All plans)	UT Transfer Verification Form (All plans)
Comparison of Traditional, Roth 403(b), and Roth IRA Contributions	Comparison of Traditional, Roth 403(b), and Roth IRA Contributions
Retirement Eligibility Tool	Retirement Eligibility Tool
ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE	ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE
UTSaver TSA Disclosure Form	UTSaver TSA Disclosure Form
Annual Eligibility Notice for Retirement Plans	Annual Eligibility Notice for Retirement Plans
DCP Purchase Agreement	DCP Purchase Agreement
Voluntary Retirement Programs At a Glance	Voluntary Retirement Programs
Vesting/Termination Status Form	Vesting/Termination Status Form
ORP Acknowledgement	ORP Acknowledgement
Purchase Change Agreement (All plans)	UT Retirement Purchase Change Agreement (All plans)
Vendor Services	Vendor Services for Retirement Participants
ORP Authorization for Reduction for Employee Contribution	ORP Authorization for Reduction for Employee Contribution
TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program and/or Refund)	TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program and/or Refund)
DCP Catch-Up Provision Agreement	DCP Catch-Up Provision Agreement
Voluntary Retirement Programs Loan and Hardship Options	Voluntary Retirement Programs Loan and Hardship Options

UT Benefits Billing

Personal Information and Emergency Contact Form	Personal Information and Emergency Contact Form
Helpful Hints for Completing the Direct Payment Agreement	Helpful Hints for Completing the Direct Payment Agreement
UT Benefits Billing Direct Payment/Debit Authorization Agreement	Direct Payment/Debit Authorization Agreement
UT Benefits Billing Reference Guide	UT Benefits Billing Reference Guide

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