Forms and Publications | University of Texas System

Forms and Publications

Forms and Publications

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Benefits Handbooks and Cost Worksheet
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

Retirement Plan Documents

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

Benefits Handbooks and Cost Worksheet

UT Benefits Handbook for Retired Employees 2014-2015	UT Benefits Handbook for Retired Employees 2014-2015
Benefits Cost Worksheet for Retired Employees 2014-2015	Cost Worksheet for Retired Employees for 2014-2015
UT Benefits Handbook for Employees 2014-2015	UT Benefits Handbook for Employees 2014-2015
Benefits Cost Worksheet for Employees 2014-2015	Cost Worksheet for Employees for 2014-2015

Medical

UT SELECT Weight Management Program	Weight Management Program
UT SELECT Medical Health Resources and Tools	UT SELECT Medical Health Resources & Tools
24/7 Nurseline	24/7 Nurseline
UT SELECT Benefits Summary Chart	UT SELECT Medical Summary Chart
Tobacco Premium Program Declaration Form	Tobacco Premium Program Declaration Form
UT SELECT Medical Claim Form	UT SELECT Medical Claim Form
UT SELECT Tobacco Cessation Program	UT SELECT Tobacco Cessation Program
UT SELECT Medical Plan Guide with Prescription Drug Coverage	2014-15 UT SELECT Benefits Guide
UT SELECT Highlights	UT SELECT Medical Plan Highlights
Physician Statement Concerning Tobacco Usage and Fitness to Participate in a Tobacco Cessation Program	Tobacco Cessation Program Physician Statement

Pharmacy

Coordination of Benefits/Direct Claim Form	Coordination of Benefits/Direct Claim Form
Prescription Drug Reimbursement Form	Prescription Drug Reimbursement Form
Prescription Drug Co-payments at a Glance	Prescription Drug Copayments at a Glance
Prescriptions by Mail Order Form	Prescription Mail Order Form 2014-2015

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 2014-2015	UT SELECT DENTAL Benefits Guide 2014-2015
Delta Dental Online Services	Delta Dental Online Services
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 2014-2015	UT SELECT DENTAL Plus Benefits Guide 2014-2015
UT SELECT DENTAL Plus Plan - ADDENDUM	UT SELECT DENTAL Plus Plan ADDENDUM
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

Smart Alert - Partnering for Total Wellness	Superior Vision Smart Alert
Superior Vision Plan Brochure	Superior Vision Plan Brochure
Superior Vision Plus Benefits Guide	Superior Vision Plus Benefits Guide
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 Plan Highlights	Superior Vision Highlights
Superior Vision Benefits Guide	visionguide.pdf
Superior Vison Claim Form	Superior Vison Claim Form
Finding-In-Network Providers	Finding-In-Network Providers

Flexible Spending Accounts

UT FLEX Benefits Guide	UT FLEX Benefits Guide
The PayFlex Card Flyer	The PayFlex Card
Payflex Mobile Application Flyer	Payflex Mobile Application Flyer
UT FLEX Direct Deposit Authorization Form	Direct Deposit Authorization Form
HealthHub (utflex.com) Quick Reference Guide	HealthHub (utflex.com) Quick Reference Guide
Flexible Spending Accounts (FSA) Flyer	Flexible Spending Accounts
UT FLEX Claim Form	UT FLEX Claim Form
UT FLEX Letter of Medical Necessity Form	Letter of Medical Necessity

Life and Accidental Death and Dismemberment (AD&D)

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
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

Short-Term Disability (STD)

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

Long-Term Disability (LTD)

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

Long-Term Care

Long-Term Care Highlights	LTC Highlights
Your Solution to Long Term Care	Your Solution to Long Term Care
Long-Term Care Short Form Application for current employees and spouses	LTC Short Form Application for current employees and spouses
Long-Term Care Benefits Guide	ltcguide.pdf
Long-Term Care Outline of Coverage	LTC Outline of Coverage
Reasons to Consider Long Term Care	Reasons to Consider Long Term Care
Long-Term Care Enrollment Form for new employees	LTC Enrollment Form for New Employees
Long-Term Care Long Form Application for all other applicants	LTC Long Form Application for all other applicants

Special Notices

HIPAA Staff Assistance Authorization	HIPAA Staff Assistance Authorization
SWIAC By-Laws	SWIAC By-laws
Notice of Creditable Coverage (NOCC)	Medicare Part D Notice of Creditable Coverage
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
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

Other

UT System Cafeteria Plan Document	UT System Cafeteria Plan Document
International Travel Quick Reference Sheet	UT System Foreign Coverage Quick Reference Sheet

UT Retirement Program

Vesting/Termination Status Form	Vesting/Termination Status Form
UTSaver TSA - 403(b) Plan Document	UTSaver TSA - 403(b) Plan Document
ORP Acknowledgement	ORP Acknowledgement
DCP Catch-Up Provision Agreement	DCP Catch-Up Provision Agreement
Purchase Change Agreement (All plans)	UT Retirement Purchase Change Agreement (All plans)
Voluntary Retirement Programs At a Glance	UT Saver Voluntary Retirement Programs Summary
Vendor Services	Vendor Services for Retirement Participants
Retirement Eligibility Tool	Retirement Eligibility Tool
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)
Voluntary Retirement Programs Loan and Hardship Options	Voluntary Retirement Programs Loan and Hardship Options
UTSaver TSA Disclosure Form	UTSaver TSA Disclosure Form
UT Transfer Verification Form (All plans)	UT Transfer Verification Form (All plans)
DCP Purchase Agreement	DCP Purchase Agreement
Summary of Retirement Programs	Retirement Programs Summary
Comparison of Traditional, Roth 403(b), and Roth IRA Contributions	Comparison of Traditional, Roth 403(b), and Roth IRA Contributions
Overview of TRS and ORP	TRS and ORP Overview - August 2014
Annual Eligibility Notice for Retirement Plans	Annual Eligibility Notice for Retirement Plans
ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE	ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE

UT Benefits Billing

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
Personal Information and Emergency Contact Form	Personal Information and Emergency Contact Form

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