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Benefit Forms

Health Care, Vision and Dental Plans
	Understanding Your UnitedHealthcare Explanation of Benefits Statement
	Understanding Your UnitedHealthcare Health Statement
	UnitedHealthcare Health Claim Form
	UnitedHealthcare International Health Claim Form
	UnitedHealthcare HIPAA Disclosure Authorization Form
	Waiver of Coverage Form
	UnitedHealthcare Provider Nomination
	Authorization Agreement for Pre-Arranged Payments (ACH Debits) Form
	Humana Authorization Agreement for Pre-Arranged Payments (ACH Debits) Form
	Davis Vision Provider Listing
	Davis Vision Reimbursement Claim Form
	DeltaCare Dental HMO Enrollment Form
	Delta Dental-How to Find a Dentist

Pharmacy Benefits
	Mail Order Form
	Pharmacy Reimbursement Claim Form
	Prescription Drug List Reference Guide
	IRS-Approved Consumer Choice (CDHP) Maintenance Medications

Flexible Spending Accounts
	Flexible Spending Account Brochure
	Flexible Spending Account Eligible Expenses
	Flexible Spending Account Health Care Claim Form
	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