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Benefits Forms

Following is a list of Benefits related forms.  If you do not find the form you are looking for, it may be listed under a different category.

Health Forms and Resources

2013 Benefits Guide

Medical - BlueCross BlueShield of Texas
$1,000/$2,000 Deductible Summary Plan Description
$2,500 Deductible PPO with HSA Summary Plan Description
Medical Claim Form
SMU Preventive Care Guidelines
Student Certification

Prescription - Express Scripts (formerly Medco)
Claim Form
Health, Allergy & Medical Questionnaire
Mail Order Form

Dental - BlueCross BlueShield of Texas
Benefits Highlights
Claim Form
Summary Plan Description

Vision - VSP
Benefits Summary
Out-of-Network Claim Form

Flexible Spending Accounts - Discovery Benefits
Automatic Dependent Care Request Form
Automatic Orthodontia Request Form
Direct Deposit Enrollment/Change Form
Reimbursement Request Form
Instructions: Request a Debit Card Online
Medical Necessity Form
Receipt and Substantiation Form

Medical/Dental/Vision Rates
Benefits Rates

Life and Disability Insurance - Reliance Standard
Beneficiary Designation Form
Evidence of Insurability Form
Summary Plan Description - Accidental Death & Dismemberment
Summary Plan Description - Long-Term Disability
Summary Plan Description - Supplemental Life Insurance
Travel Assistance Brochure - WorldNet

Long-Term Care - CNA
Detailed Plan Information Booklet
Employee Enrollment Form
Employee Enrollment Form Instructions
Long Form Application
Long Form Instructions
Short Form Application
Short Form Instructions
Rates-Parents, etc.

 Leave of Absence
Family Medical Leave Act - Certification for Dependents
Family Medical Leave Act - Certification of Health Provider
Leave of Absence Form - Staff

 

Retirement Forms and Resources

Emeriti
Emeriti ADV Privacy Notice
Emeriti Frequently Asked Questions

Medicare
Medicare and You 2013
Retiring from SMU

 

Miscellaneous

Miscellaneous
Change of Name Form
COBRA Benefits Guide
COBRA Benefits Highlights
COBRA Rates
Dissolution of Domestic Partnership
Statement of Domestic Partnership
Termination Form

If you have questions, please contact us at the following:

Email Us benefitsu@smu.edu
Call Us 214-768-3311