Forms and Publications

Special Notices
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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
BAC By-LawsEmployee Benefits BAC By-laws
HIPAA Breach LogEmployee Benefits HIPAA Breach Log
HIPAA Complaint FormEmployee Benefits HIPAA Complaint Form
HIPAA General Authorization FormEmployee Benefits HIPAA General Authorization Form
HIPAA Notice of Privacy PracticesEmployee Benefits HIPAA Notice of Privacy Practices
HIPAA Request for Access to Protected Health InformationEmployee Benefits Request for Access Form
HIPAA Request for Accounting of DisclosuresEmployee Benefits HIPAA Request for Accounting of Disclosues Form
HIPAA Request for Amendment of Protected Health InformationEmployee Benefits HIPAA Request for Amendment of Protected Health Information Form
HIPAA Request for Confidential Communications of Medical InformationEmployee Benefits HIPAA Request for Confidential Communications of Medical Information Form
HIPAA Request for Restriction on Use or Disclosure of Protected Health InformationEmployee Benefits HIPAA Request for Restriction Form
HIPAA Revocation of AuthorizationEmployee Benefits HIPAA Revocation of Authorization Form
HIPAA Staff Assistance AuthorizationEmployee Benefits HIPAA Staff Assistance Authorization
Legal NoticesEmployee Benefits UT Benefits - Legal Notices
Medicaid and the Children's Health Insurance Program (CHIP) NoticeEmployee Benefits Medicaid and CHIP Notice
Nondiscrimination and Accessibility NoticeEmployee Benefits Nondiscrimination and Accessibility Notice
Notice of Creditable Coverage (NOCC)Employee Benefits Medicare Part D Notice of Creditable Coverage
UT Retirement Program
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Annual Eligibility Notice for Retirement PlansEmployee Benefits Annual Eligibility Notice for Retirement Plans
Comparison of Traditional, Roth 403(b), and Roth IRA ContributionsEmployee Benefits Comparison of Traditional, Roth 403(b), and Roth IRA Contributions
DCP Catch-Up Provision AgreementEmployee Benefits DCP Catch-Up Provision Agreement
DCP Purchase AgreementEmployee Benefits DCP Purchase Agreement
ORP AcknowledgementEmployee Benefits ORP Acknowledgement
ORP Authorization for Reduction for Employee ContributionEmployee Benefits ORP Authorization for Reduction for Employee Contribution
ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEEEmployee Benefits ORP Authorization for Reduction for Employee Contribution RETURNING EMPLOYEE
Overview of TRS and ORPEmployee Benefits TRS and ORP Overview - August 2015
Purchase Change Agreement (All plans)Employee Benefits UT Retirement Purchase Change Agreement (All plans)
Summary of Retirement ProgramsEmployee Benefits Retirement Programs Summary
TRS Form 28 (Notice to Elect to Participate in Optional Retirement Program and/or Refund)Employee Benefits TRS Form 28
UT Transfer Verification Form (All plans)Employee Benefits UT Transfer Verification Form (All plans)
UTSaver TSA Disclosure FormEmployee Benefits UTSaver TSA Disclosure Form
Vendor ServicesEmployee Benefits Vendor Services for Retirement Participants
Vesting/Termination Status FormEmployee Benefits Vesting/Termination Status Form
Voluntary Retirement Programs At a GlanceEmployee Benefits Voluntary Retirement Programs
Voluntary Retirement Programs Loan and Hardship OptionsEmployee Benefits Voluntary Retirement Programs Loan and Hardship Options
Benefits Handbooks and Cost Worksheet
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Annual Enrollment & Resource Guide for Employees 2016-2017Employee Benefits Annual Enrollment & Resource Guide for Employees 2016-2017
Annual Enrollment & Resource Guide for Employees 2017-2018Employee Benefits 2017-2018 Annual Enrollment & Resources Guide for Employees
Annual Enrollment & Resource Guide for Retired Employees 2016-2017Employee Benefits Annual Enrollment & Resource Guide for Retired Employees 2016-2017
Annual Enrollment & Resource Guide for Retirees 2017-2018Employee Benefits 2017-2018 Annual Enrollment & Resources Guide for Retirees
Benefits Cost Worksheet for Employee 2016-2017Employee Benefits Benefits Cost Worksheet for Employee 2016-2017
Benefits Cost Worksheet for Employees 2017-2018Employee Benefits Active Employee Cost Worksheet 2017-2018
Benefits Cost Worksheet for Retired Employee 2016-2017Employee Benefits Benefits Cost Worksheet for Retired Employee 2016-2017
Benefits Cost Worksheet for Retired Employees 2017-2018Employee Benefits Retired Employee Cost Worksheet 2017-2018
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
UT Benefits Enrollment Guide for Employees 2016-2017Employee Benefits UT Benefits Enrollment Guide for Employees 2016-2017
UT Benefits Enrollment Guide for Retiring Employees 2016-2017Employee Benefits UT Benefits Enrollment Guide for Retiring Employees 2016-2017
Dental
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Delta Dental Online ServicesEmployee Benefits Delta Dental Online Services
DeltaCare - Getting the Most from Your Dental HMOEmployee Benefits Getting the Most from Your Dental HMO
DeltaCare Benefits GuideEmployee Benefits DeltaCare Benefits Guide
DeltaCare HighlightsEmployee Benefits DeltaCare Highlights
Recommend Your DentistEmployee Benefits Recommend Your Dentist
SmileWaySM Wellness Program: Take the ChallengeEmployee Benefits SmileWaySM Wellness Program
The Connection Between Your Oral and Overall HealthEmployee Benefits Your Oral and Overall Health
UT SELECT DENTAL - Getting the Most from Your DPO NetworkEmployee Benefits Getting the Most from Your DPO Network
UT SELECT DENTAL Benefits Guide 2016-2017Employee Benefits UT SELECT DENTAL Benefits Guide 2016-2017
UT SELECT DENTAL Benefits Guide 2017-2018Employee Benefits UT SELECT DENTAL Benefits Guide 2017-2018
UT SELECT DENTAL Claim FormEmployee Benefits UT SELECT DENTAL Claim Form
UT SELECT DENTAL HighlightsEmployee Benefits UT SELECT DENTAL Highlights
UT SELECT DENTAL Plus Benefits Guide 2016-2017Employee Benefits UT SELECT DENTAL Plus Benefits Guide 2016-2017
UT SELECT DENTAL Plus Benefits Guide 2017-2018Employee Benefits UT SELECT DENTAL Plus Benefits Guide 2017-2018
UT SELECT DENTAL Plus HighlightsEmployee Benefits UT SELECT DENTAL Plus Highlights
Your Dental Plan OptionsEmployee Benefits Dental Plan Options
Long-Term Care
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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
Long-Term Disability (LTD)
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Long-Term Disability Benefit HighlightsEmployee Benefits LTD Benefit Highlights 2017.pdf
Long-Term Disability Benefits GuideEmployee Benefits Long Term Disability Guide
Long-Term Disability Conversion KitEmployee Benefits LTD Conversion Kit
LTD Conversion CalculatorEmployee Benefits LTD Conversion Calculator
LTD Employee Claim FormEmployee Benefits LTD Employee Claim Form
LTD Employer Claim FormEmployee Benefits LTD Employer Claim Form