UTHSC-H Finance - Benefits - Insurance Forms

... Insurance Forms

Listed below in alphabetical order, is a list of insurance forms that are currently utilized by The University of Texas Health Science Center at Houston. (Insurance Forms From A-Z)

BlueCross BlueShield Claim Form Delta Dental Claim Form

Dependent Enrollment/Change Form Merck-Medco Drug Claim Form

EGI - Staff Assistance Authorization Form - HIPAA Merck-Medco Mail-Order Form

Employee Only Basic Coverage Notification Payflex Direct Deposit Reimbursement Form

Fort Dearborn Life Beneficiary Form Payflex Health Care & Dependent Care Reimbursement Claim Form

Employee Insurance Enrollment/Change Form Payflex Salary Conversion Agreement

UT Select Direct Claim Form Standard Beneficiary Designation/Change Form

Change of Status Form

Zip Code Exception for Group Medical Insurance

Evidence of Insurability Forms

Certificate of Group Health Plan Coverage Hartford STD and LTD EOI Form

Fort Dearborn Life Insurance EOI Form UT Select EOI Form

Please forward completed copies to:

The University of Texas Health Science Center
University Center Tower
Benefits Department
7000 Fannin, 10th Floor
P.O. Box 20036
Houston TX 77225

The University of Texas Health Science Center at Houston
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Last updated September 3, 2008