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

Benefits Handbooks and Cost Worksheet

UT Benefits Handbook for Retired Employees	UT Benefits Handbook for Retired Employees 2013-2014 Errata: Please note errata applies only to the printed copies of this handbook, and not the digital version.
Benefits Cost Worksheet for Employees	Cost Worksheet for Employees for 2013-2014
Benefits Cost Worksheet for Employees 2014-2015	Cost Worksheet for Employees for 2014-2015
Benefits Cost Worksheet for Retired Employees	Cost Worksheet for Retired Employees for 2013-2014
UT Benefits Handbook for Employees	UT Benefits Handbook for Employees 2013-2014
Benefits Cost Worksheet for Retired Employees 2014-2015	Cost Worksheet for Retired Employees for 2014-2015

Medical

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 Benefits Summary Chart	UT SELECT Medical Summary Chart
UT SELECT Medical Plan Guide with Prescription Drug Coverage	UTSelect Medical Guide
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 Medical Health Resources and Tools	UT SELECT Medical Health Resources & Tools
UT SELECT Highlights	UT SELECT Medical Plan Highlights

Pharmacy

Coordination of Benefits/Direct Claim Form	Coordination of Benefits/Direct Claim Form
Medco by Mail Order Form	Prescriptions by Mail Order Form
Prescription Drug Reimbursement Form	Prescription Drug Reimbursement Form
Prescription Drug Co-payments at a Glance	medicalpresataglance.pdf

Dental

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
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	UT SELECT DENTAL Benefits Guide
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
Delta Dental Online Services	Delta Dental Online Services

Vision

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

Flexible Spending Accounts

UT FLEX Letter of Medical Necessity Form	Letter of Medical Necessity
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

Life and Accidental Death and Dismemberment (AD&D)

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
Create Your Own Will Online	Create Your Own Will Online
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
Beneficiary Designation Form	Beneficiary Designation Form
Group Term Life Benefits Guide	GTL Benefits Guide
Life/AD&D Benefit Highlights for Active Employees	Life/AD&D Benefit Highlights for Active Employees

Short-Term Disability (STD)

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

Long-Term Disability (LTD)

Long-Term Disability Benefits Guide	Long-Term Disability Benefits Guide
LTD Employee Claim Form	LTD Employee Claim Form
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 Care

Long-Term Care Long Form Application for all other applicants	LTC Long Form Application for all other applicants
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

Special Notices

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)	Notice of Creditable Coverage
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
Early Retiree Reinsurance Program (ERRP) Notice and Q&As	ERRP Notice and Q&As
HIPAA Notice of Privacy Practices	HIPAA Notice of Privacy Practices
HIPAA Complaint Form	HIPAA Complaint Form

Other

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

UT Benefits Billing

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
Helpful Hints for Completing the Direct Payment Agreement	Helpful Hints for Completing the Direct Payment Agreement

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ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE	ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE
Vesting/Termination Status Form	Vesting/Termination Status Form
Voluntary Retirement Programs Transfer Verification Form	Voluntary Retirement Programs Transfer Verification Form
UTSaver TSA Disclosure Form	UTSaver TSA Disclosure Form
Optional Retirement Program (ORP) Plan Document	Optional Retirement Program (ORP) Plan Document
UTSaver DCP - 457(b) Plan Document	UTSaver DCP - 457(b) Plan Document
Retirement Eligibility Tool	Retirement Eligibility Tool
DCP Purchase Agreement	DCP Purchase Agreement
Overview of TRS and ORP	Overview of TRS and ORP
Voluntary Retirement Programs At a Glance	Retirement Programs Summary
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 - 403(b) Plan Document	UTSaver TSA - 403(b) Plan Document
Summary of Retirement Programs	Summary of Retirement Programs
Purchase/Change form for TSA (Traditional or Roth)-ORP changes	Purchase/Change form for TSA (Traditional or Roth)-ORP changes
Vendor Services	Vendor Services for Retirement Participants
DCP Catch-Up Provision Agreement	DCP Catch-Up Provision Agreement
Annual Eligibility Notice for Retirement Plans	Annual Eligibility Notice for Retirement Plans
Comparison of Traditional, Roth 403(b), and Roth IRA Contributions	Comparison of Traditional, Roth 403(b), and Roth IRA Contributions
ORP Acknowledgement	ORP Acknowledgement