Forms and Publications

Medical
DocumentOfficePublish DateFile
UT SELECT Medical Claim FormEmployee Benefits UT SELECT Medical Claim Form
Physician Statement Concerning Tobacco Usage and Fitness to Participate in a Tobacco Cessation ProgramEmployee Benefits Tobacco Cessation Program Physician Statement
UT SELECT Tobacco Cessation ProgramEmployee Benefits UT SELECT Tobacco Cessation Program
UT SELECT Weight Management ProgramWeight Management Program
Tobacco Premium Program Declaration FormEmployee Benefits Tobacco Premium Program Declaration Form
24/7 NurselineEmployee Benefits 24/7 Nurseline
UT SELECT Medical Plan Guide with Prescription Drug CoverageEmployee Benefits 2017-2018 UT SELECT Benefits Guide
2016-2017 UT SELECT Benefits Guide
UT SELECT Benefits Summary ChartEmployee Benefits UT SELECT Benefits Summary Chart 2017-2018
PPO Network Summary of Benefits and CoverageEmployee Benefits 2018-2019 Summary of Benefits Summary: PPO Plan
2018-2019 Summary of Benefits Summary: PPO Plan (Spanish/Español)
Out-of-Area Network Summary of Benefits and CoverageEmployee Benefits 2018-2019 Summary of Benefits and Coverage: Out-of-Area Plan
2018-2019 Summary of Benefits and Coverage: Out-of-Area Plan (Spanish/Español)
UT CONNECT ACO Medical Plan FAQsEmployee Benefits UT CONNECT-faqs-2018-2019
Glossary of Health Coverage and Medical TermsEmployee Benefits Glossary of Health Coverage and Medical Terms
UT Health Network FlyerEmployee Benefits UT Health Network Flyer 2017-2018
UT Health Network Flyer 2018-2019
Short-Term Disability (STD)
DocumentOfficePublish DateFile
STD Integrated Medical/DisabilitySTD Integrated Medical/Disability
Short-Term Disability Benefits GuideEmployee Benefits Short Term Disability Guide
Filing Your STD ClaimEmployee Benefits Filing Your STD Claim
STD Benefit HighlightsEmployee Benefits STD Benefit Highlights
Long-Term Disability (LTD)
DocumentOfficePublish DateFile
LTD Conversion CalculatorEmployee Benefits LTD Conversion Calculator
LTD Employee Claim FormEmployee Benefits LTD Employee Claim Form
Long-Term Disability Conversion KitEmployee Benefits LTD Conversion Kit
Long-Term Disability Benefits GuideEmployee Benefits Long Term Disability Guide
LTD Employer Claim FormEmployee Benefits LTD Employer Claim Form
Long-Term Disability Benefit HighlightsEmployee Benefits LTD Benefit Highlights 2017.pdf
Long-Term Care
DocumentOfficePublish DateFile
Long-Term Care Benefits GuideEmployee Benefits ltcguide.pdf
Long-Term Care HighlightsEmployee Benefits LTC Highlights
Long-Term Care Outline of CoverageEmployee Benefits LTC Outline of Coverage
Special Notices
DocumentOfficePublish DateFile
HIPAA Request for Amendment of Protected Health InformationEmployee Benefits HIPAA Request for Amendment of Protected Health Information Form
HIPAA Request for Restriction on Use or Disclosure of Protected Health InformationEmployee Benefits HIPAA Request for Restriction Form
HIPAA Breach LogEmployee Benefits HIPAA Breach Log
HIPAA Request for Confidential Communications of Medical InformationEmployee Benefits HIPAA Request for Confidential Communications of Medical Information Form
Notice of Creditable Coverage (NOCC)Employee Benefits Medicare Part D Notice of Creditable Coverage
HIPAA Staff Assistance AuthorizationEmployee Benefits HIPAA Staff Assistance Authorization
HIPAA Complaint FormEmployee Benefits HIPAA Complaint Form
HIPAA General Authorization FormEmployee Benefits HIPAA General Authorization Form
HIPAA Request for Access to Protected Health InformationEmployee Benefits Request for Access Form
HIPAA Revocation of AuthorizationEmployee Benefits HIPAA Revocation of Authorization Form
HIPAA Request for Accounting of DisclosuresEmployee Benefits HIPAA Request for Accounting of Disclosues Form
BAC By-LawsEmployee Benefits BAC By-laws
Nondiscrimination and Accessibility NoticeEmployee Benefits Nondiscrimination and Accessibility Notice
Affordable Care Act - Marketplace NoticesEmployee Benefits UT Arlington ACA Notice
UT Austin ACA Notice
UT Dallas ACA Notice
UT El Paso ACA Notice
UT Health Houston ACA Notice
UT Health San Antonio ACA Notice
UT Health Northeast ACA Notice
UT Medical Branch Galveston ACA Notice
UT MD Anderson Cancer Center ACA Notice
UT Permian Basin ACA Notice
UT Rio Grande Valley ACA Notice
UT San Antonio ACA Notice
UT Southwestern Medical Center ACA Notice
UT System Administration ACA Notice
UT Tyler ACA Notice
Medicaid and the Children's Health Insurance Program (CHIP) NoticeEmployee Benefits Medicaid and the Children's Health Insurance Program (CHIP) Notice
Legal NoticesEmployee Benefits UT Benefits - Legal Notices 2017
UT Benefits - Legal Notices 2018
UT Retirement Program
DocumentOfficePublish DateFile
Purchase Change Agreement (All plans)Employee Benefits UT Retirement Purchase Change Agreement (All plans)
ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEEEmployee Benefits ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE
UT Transfer Verification Form (All plans)Employee Benefits UT Transfer Verification Form (All plans)
UTSaver TSA Disclosure FormEmployee Benefits UTSaver TSA Disclosure Form
ORP Authorization for Reduction for Employee ContributionEmployee Benefits ORP Authorization for Reduction for Employee Contribution
DCP Catch-Up Provision AgreementEmployee Benefits DCP Catch-Up Provision Agreement
Vendor ServicesEmployee Benefits Vendor Services for Retirement Participants
ORP AcknowledgementEmployee Benefits ORP Acknowledgement
Overview of TRS and ORPEmployee Benefits TRS and ORP Overview - August 2015
Vesting/Termination Status FormEmployee Benefits Vesting/Termination Status Form
TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program and/or Refund)Employee Benefits TRS Form 28
Voluntary Retirement Programs Loan and Hardship OptionsEmployee Benefits Voluntary Retirement Programs Loan and Hardship Options
Summary of Retirement ProgramsEmployee Benefits Retirement Programs Summary
Comparison of Traditional, Roth 403(b), and Roth IRA ContributionsEmployee Benefits Comparison of Traditional, Roth 403(b), and Roth IRA Contributions
Voluntary Retirement Programs At a GlanceEmployee Benefits Voluntary Retirement Programs
Annual Eligibility Notice for Retirement PlansEmployee Benefits Annual Eligibility Notice for Retirement Plans
DCP Purchase AgreementEmployee Benefits DCP Purchase Agreement
Benefits Handbooks and Cost Worksheet
DocumentOfficePublish DateFile
Benefits Overview for Employees 2016-2017Employee Benefits Benefits Overview for Employees 2016-2017
Benefits Overview for Retired Employees 2016-2017Employee Benefits Benefits Overview for Retired Employees 2016-2017
Benefits Cost Worksheet for Retired Employees 2017-2018Employee Benefits Retired Employee Cost Worksheet 2017-2018
Benefits Cost Worksheet for Employees 2017-2018Employee Benefits Active Employee Cost Worksheet 2017-2018
Annual Enrollment & Resource Guide for Employees 2017-2018Employee Benefits 2017-2018 Annual Enrollment & Resources Guide for Employees
Annual Enrollment & Resource Guide for Retirees 2017-2018Employee Benefits 2017-2018 Annual Enrollment & Resources Guide for Retirees
UT Benefits Enrollment Guide for Employees 2017-2018Employee Benefits UT Benefits Enrollment Guide for Employees 2017-2018
UT Benefits Enrollment Guide for Retiring Employees 2017-2018Employee Benefits UT Benefits Enrollment Guide for Retiring Employees 2017-2018
Benefits Cost Worksheet for Employees 2018-2019Employee Benefits Active Employee Cost Worksheet 2018-2019
Annual Enrollment & Resource Guide for Employees for 2018-2019Employee Benefits 2018-2019 Annual Enrollment & Resource Guide for Employees
Benefits Cost Worksheet for Retired Employees 2018-2019Employee Benefits Retired Employee Cost Worksheet 2018-2019
Annual Enrollment & Resource Guide for Retired Employees for 2018-2019Employee Benefits 2018-2019 Annual Enrollment & Resource Guide for Retired Employees