Forms and Publications

Forms and Publications
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Some 2015-2016 publications are currently being finalized. Guides and other items for the new plan year are being added to this page as they become available.


Retirement Plan Documents
UTSaver DCP - 457(b) Plan Document
UTSaver TSA - 403(b) Plan Document
Optional Retirement Program (ORP) Plan Document
Benefits Handbooks and Cost Worksheet
Annual Enrollment & Resource Guide for Employees 2015-2016
Benefits Cost Worksheet for Retired Employees 2015-2016
Annual Enrollment & Resource Guide for Retired Employees 2015-2016
UT Benefits Enrollment Guide for Employees 2015-2016
Benefits Cost Worksheet for Employees 2015-2016
UT SELECT Highlights
24/7 Nurseline
Physician Statement Concerning Tobacco Usage and Fitness to Participate in a Tobacco Cessation Program
UT SELECT Weight Management Program
UT SELECT Medical Health Resources and Tools
UT SELECT Medical Plan Guide with Prescription Drug Coverage
UT SELECT Benefits Summary Chart
Tobacco Premium Program Declaration Form
UT SELECT Medical Claim Form
UT SELECT Tobacco Cessation Program
Prescription Drug Co-payments at a Glance
Prescriptions by Mail Order Form
Coordination of Benefits/Direct Claim Form
Prescription Drug Reimbursement Form
UT SELECT DENTAL Benefits Guide 2015-2016
The Connection Between Your Oral and Overall Health
Your Dental Plan Options
DeltaCare Benefits Guide
UT SELECT DENTAL Plus Highlights
UT SELECT DENTAL PLUS Benefits Guide 2015-2016
Delta Dental Online Services
SmileWaySM Wellness Program: Take the Challenge
Recommend Your Dentist
DeltaCare - Getting the Most from Your Dental HMO
DeltaCare Highlights
UT SELECT DENTAL - Getting the Most from Your DPO Network
Superior Vision Benefits Guide
Provider Nomination Form
Quality LASIK for Texas Members - Online Contact Lens Ordering
Getting Started with the Online Member Portal
Superior Vision Plus Benefits Guide
Superior Vision Plan Highlights
Superior Vison Claim Form
Finding-In-Network Providers
Smart Alert - Partnering for Total Wellness
Superior Vision Plan Brochure
Flexible Spending Accounts
HealthHub ( Quick Reference Guide
Flexible Spending Accounts (FSA) Flyer
UT FLEX Claim Form
UT FLEX Letter of Medical Necessity Form
UT FLEX Benefits Guide
The PayFlex Card Flyer
Payflex Mobile Application Flyer
UT FLEX Direct Deposit Authorization Form
Life and Accidental Death and Dismemberment (AD&D)
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
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
Short-Term Disability (STD)
STD Benefit Highlights
STD Integrated Medical/Disability
Filing Your STD Claim
Short-Term Disability Benefits Guide
Long-Term Disability (LTD)
Long-Term Disability Benefits Guide
LTD Employee Claim Form
Long-Term Disability Conversion Kit
Long-Term Disability Benefit Highlights
LTD Employer Claim Form
LTD Conversion Calculator
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
Legal Notices
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
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
COBRA General Notice
International Travel Quick Reference Sheet
UT System Cafeteria Plan Document
UT Retirement Program
Voluntary Retirement Programs At a Glance
Annual Eligibility Notice for Retirement Plans
UT Transfer Verification Form (All plans)
Comparison of Traditional, Roth 403(b), and Roth IRA Contributions
Retirement Eligibility Tool
ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE
Vesting/Termination Status Form
UTSaver TSA Disclosure Form
Overview of TRS and ORP
DCP Purchase Agreement
Summary of Retirement Programs
ORP Acknowledgement
Purchase Change Agreement (All plans)
Vendor Services
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
DCP Catch-Up Provision Agreement
UT Benefits Billing
Personal Information and Emergency Contact Form
Helpful Hints for Completing the Direct Payment Agreement
UT Benefits Billing Direct Payment/Debit Authorization Agreement
UT Benefits Billing Reference Guide © 2015 The University of Texas System.
601 Colorado Street, Austin, Texas 78701-2982. (512)499-4200