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Benefit Forms

Health Care, Vision and Dental Plans
	Understanding Your UHC Monthly Statement
	Health Claim Form
	International Health Claim Form
	UnitedHealthcare HIPAA Disclosure Authorization Form
	Davis Vision Provider Listing
	Davis Vision Reimbursement Claim Form
	SafeGuard HMO & CitiDent PPO Comparison
	CitiDent PPO Plan Overview
	CitiDent PPO Provider Directory
	SafeGuard Dental HMO Plan Overview
	SafeGuard Dental HMO Provider Directory
	CitiDent PPO Claim Form
	SafeGuard Dental HMO Enrollment Form
	SafeGuard/MetLife DHMO Change Form
	How to Access Dental Directories
	SafeGuard/MetLife Continuing Orthodontic Treatment Policy Form
	Waiver of Coverage Form
	Provider Nomination
	Authorization Agreement for Pre-Arranged Payments (ACH Debits) Form
	Humana Authorization Agreement for Pre-Arranged Payments (ACH Debits) Form

Prescription Drug Benefits
	Mail Order Form
	Pharmacy Reimbursement Claim Form
	Prescription Drug List Reference Guide

Flexible Spending Accounts
	Flexible Spending Account Brochure
	2012 Flexible Spending Account Eligible Expenses
	2012 Flexible Spending Account Healthcare Claim Form
	2012 Flexible Spending Account Dependent Care Claim Form
	FSA-How To Use The Card

Life Insurance
	Dearborn National: Evidence of Insurability (Online) Application
	Dearborn National: Evidence of Insurability Form (English)
	Dearborn National: Beneficiary Form
	Dearborn National: Evidence of Insurability Form (Spanish)
	Dearborn National: Beneficiary Form (Spanish)
	Dearborn National: Plan Summary for the City of San Antonio(English)
	Dearborn National: Plan Summary for the City of San Antonio (Spanish)
	Dearborn National: Plan Certificate of Coverage (Civilian)

Deferred Compensation (457) Plans
	457 ICMA-RC Employee Information Change
	457 ICMA-RC Enrollment Form
	457 ICMA-RC Amount of Deferral Change
	457 Nationwide Enrollment Form
	457 Nationwide Retirement Solutions Payroll Authorization Card
	457 Nationwide Change of Beneficiary

Texas Municipal Retirement System
	TMRS: Service Retirement Checklist
	TMRS: Address or Name Change Form
	TMRS: Direct Deposit Authorization
	TMRS: Change of Beneficiary for Vested Members
	TMRS: Change of Beneficiary for Non-Vested Members
	TMRS: Restricted Prior Service Credit
	TMRS: Refund Application
	TMRS: Partial Lump Sum Distribution
	TMRS: Military Service Credit Purchase
	TMRS: Military Service Credit Time Only