Forms and Publications

Forms and Publications
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Benefits Handbooks and Cost Worksheet
UT Benefits Handbook for Retired Employees 2014-2015
Benefits Cost Worksheet for Retired Employees 2014-2015
UT Benefits Handbook for Retired Employees
Benefits Cost Worksheet for Employees
UT Benefits Handbook for Employees 2014-2015
Benefits Cost Worksheet for Employees 2014-2015
Benefits Cost Worksheet for Retired Employees
UT Benefits Handbook for Employees
Medical
UT SELECT Medical Health Resources and Tools
UT SELECT Benefits Summary Chart
Tobacco Premium Program Declaration Form
UT SELECT Medical Claim Form
UT SELECT Tobacco Cessation Program
UT SELECT Medical Plan Guide with Prescription Drug Coverage
UT SELECT Highlights
Physician Statement Concerning Tobacco Usage and Fitness to Participate in a Tobacco Cessation Program
UT SELECT Weight Management Program
Pharmacy
Prescription Drug Co-payments at a Glance
Prescriptions by Mail Order Form
Coordination of Benefits/Direct Claim Form
Prescription Drug Reimbursement Form
Dental
UT SELECT DENTAL - Getting the Most from Your DPO Network
UT SELECT DENTAL Highlights
UT SELECT DENTAL Benefits Guide 2014-2015
UT SELECT DENTAL Benefits Guide 2013-2014
UT SELECT DENTAL Plus Plan - ADDENDUM
The Connection Between Your Oral and Overall Health
Your Dental Plan Options
DeltaCare Benefits Guide
UT SELECT DENTAL Claim Form
UT SELECT DENTAL Plus Highlights
UT SELECT DENTAL PLUS Benefits Guide 2014-2015
Delta Dental Online Services
SmileWaySM Wellness Program: Take the Challenge
Recommend Your Dentist
DeltaCare - Getting the Most from Your Dental HMO
DeltaCare Highlights
Vision
Superior Vision Plan Brochure
Superior Vision Plus Benefits Guide
Provider Nomination Form
Quality LASIK for Texas Members
SVContacts.com - Online Contact Lens Ordering
Getting Started with the Online Member Portal
Superior Vision Plan Highlights
Superior Vision Benefits Guide
Superior Vison Claim Form
Finding-In-Network Providers
Smart Alert - Partnering for Total Wellness
Flexible Spending Accounts
UT FLEX Benefits Guide
The PayFlex Card Flyer
Payflex Mobile Application Flyer
UT FLEX Direct Deposit Authorization Form
HealthHub (utflex.com) Quick Reference Guide
Flexible Spending Accounts (FSA) Flyer
UT FLEX Claim Form
UT FLEX Letter of Medical Necessity Form
Life and Accidental Death and Dismemberment (AD&D)
Beneficiary Designation Form
Life/AD&D Benefit Highlights for Active Employees
Portability and Conversion of Life Insurance
Life Portability Application
Accelerated Death Claim Form
About Online Beneficiary Management
Group Term Life Benefits Guide
Accidental Death & Dismemberment Benefits Guide
Life Benefit Highlights for Retired Employees
Life Conversion Application
Death Claim Form
Accidental Dismemberment Claim Form
Create Your Own Will Online
Short-Term Disability (STD)
Filing Your STD Claim
Short-Term Disability Benefits Guide
STD Benefit Highlights
Long-Term Disability (LTD)
LTD Conversion Calculator
Long-Term Disability Benefits Guide
LTD Employee Claim Form
Long-Term Disability Conversion Kit
Long-Term Disability Benefit Highlights
LTD Employer Claim Form
Long-Term Care
Long-Term Care Outline of Coverage
Reasons to Consider Long Term Care
Long-Term Care Enrollment Form for new employees
Long-Term Care Long Form Application for all other applicants
Long-Term Care Highlights
Your Solution to Long Term Care
Long-Term Care Short Form Application for current employees and spouses
Long-Term Care Benefits Guide
Special Notices
SWIAC By-Laws
Notice of Creditable Coverage (NOCC)
HIPAA Notice of Privacy Practices
HIPAA Complaint Form
HIPAA Request for Restriction on Use or Disclosure of Protected Health Information
HIPAA Request for Amendment of Protected Health Information
HIPAA General Authorization Form
HIPAA Request for Access to Protected Health Information
Early Retiree Reinsurance Program (ERRP) Notice and Q&As
Medicaid and the Children's Health Insurance Program (CHIP) Notice
HIPAA Breach Log
HIPAA Revocation of Authorization
HIPAA Request for Confidential Communications of Medical Information
HIPAA Request for Accounting of Disclosures
HIPAA Staff Assistance Authorization
Other
UT System Cafeteria Plan Document
International Travel Quick Reference Sheet
UT Retirement Program
Purchase/Change form for TSA (Traditional or Roth)-ORP changes
Summary of Retirement Programs
DCP Catch-Up Provision Agreement
Retirement Eligibility Tool
Comparison of Traditional, Roth 403(b), and Roth IRA Contributions
ORP Acknowledgement
ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE
Vesting/Termination Status Form
Voluntary Retirement Programs Transfer Verification Form
UTSaver TSA Disclosure Form
Overview of TRS and ORP
UTSaver DCP - 457(b) Plan Document
Optional Retirement Program (ORP) Plan Document
DCP Purchase Agreement
Annual Eligibility Notice for Retirement Plans
Voluntary Retirement Programs At a Glance
ORP Authorization for Reduction for Employee Contribution
TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program and/or Refund)
Voluntary Retirement Programs Loan and Hardship Options
UTSaver TSA - 403(b) Plan Document
Vendor Services
UT Benefits Billing
UT Benefits Billing Direct Payment/Debit Authorization Agreement
UT Benefits Billing Reference Guide
Personal Information and Emergency Contact Form
Helpful Hints for Completing the Direct Payment Agreement
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