Forms for Retired Employees
Contact Info
- Human Resource Service Center
512-471-4772 (HRSC) or
1-800-687-4178 - Find HRS Reps
All forms are PDFs unless otherwise noted. PDFs require the free Adobe® Reader® or compatible software.
Enrollment/Change
- Automatic Payment Request Authorization (for Retiree Insurance Payments)
- Insurance Enrollment/Change Application
- Dependent Information
- Beneficiary Designation for Term Life
- ORP Declaration of Retirement
- Medical/Term Life Evidence of Insurability Application
- Long Term Care Enrollment (password: utsguest)
Insurance Cost
- Benefit Cost Worksheet
Medical/Prescription
- Provider Nomination Form
- UT Select Medical Claim
- UT Select Medco Pharmacy Order Form
- UT Select Prescription Claim
