Benefit Forms

We hope to move to online enrollment in the future.  But for now we rely on paper enrollment forms (see below) for almost all of our benefits.  You may deliver completed forms to our office on 4C of the Central Building, or fax to 501.686.5386 with a fax cover sheet.  Keep the original and fax confirmation for your files.  You can also scan your completed forms and email to us at If emailing, we recommend you send forms only from an internal UAMS email address so your document is secure.

If you don’t see the benefit form you need, contact Human Resources at (501) 686-5650.


How to verify your benefit change has been approved and keyed into SAP

1. Log into Employee Self Service.
2. Click on Benefits, then Benefits Participation Overview.
3. The Participation Overview as of date at the top defaults to today.  Change it to a future date - the date your change should take effect – to see the change.
4. Click on each Plan Name to view more details, such as the annual FSA amount and employer premium costs.
5. Benefits Participation Overview only shows the benefits you have.  To view a list of all benefits, including those you don’t have (a helpful tool for open enrollment), select UAMS Benefits Statement.
6.Check out the total compensation information on your Benefits Statement to see the value of  your UAMS-paid benefits.

Benefit Enrollment Forms

FOR NEW EMPLOYEES ONLY:  New Employee Benefit Form
Mark yes or no for each plan.  Name your life insurance beneficiaries.


FOR CURRENT EMPLOYEES:   Benefits Change Request Form
For employees hired more than a month ago.  Explain the reason for your mid-year change; documentation may be required.  Click here to see qualifying events. 

Life, LTD, AD&D change form (If you are past your initial one month benefit eligibility window, you must apply directly to the Standard Insurance Company via online application in order to add or increase coverage)

Also fill out the following vendor form for each plan in which you are requesting to enroll in or make a change to:

Medical enrollment form
Dental enrollment form
Vision enrollment form
Flexible Spending Account enrollment form (only for new hire and mid-year qualifying events; annual open enrollment will be offered online)

Other Benefit Forms


UMR medical claim
(if you didn’t have your insurance card and paid out of pocket)
MedImpact prescription claim
(if you didn’t have your insurance card and paid out of pocket)
(to give a spouse or others access to your medical claims)
Weight Loss Physician Attestation Form
Weight Loss Reimbursement Form


Delta Dental claim
(if you didn’t have your insurance card and paid out of pocket)


Life beneficiary change
Apply for Optional Life or Dependent Life  (if you are past your first 31 days of eligibility)
Conversion application; Portability application (convert to a private policy within 31 days of losing coverage as an employee)

Contact Human Resources first before filing one of these claims:
Claim – Life
Claim-Accidental Death & Dismemberment
Claim-Accelerated Life (access a portion of your life insurance now if diagnosed with a terminal illness)
Claim-Waiver of Premium (only needed if employee is not eligible for LTD)

Long Term Disability

Apply for Optional Long Term Disability (if you are past your first 31 days of eligibility)
Claim – LTD
(ask for help from Human Resources to complete this claim)
Application to convert to an individual policy (when your coverage as an employee ends)

Flexible Spending Accounts

Healthcare FSA claim
Dependent care FSA claim
Combined & fillable Healthcare & dependent care FSA claim
UMR FSA direct deposit

Pre-Tax Premium Conversion

Premium conversion

UA Retirement Plan

Change your retirement contribution -send us page 1, you keep page 2
Report other employer retirement contributions 2015
Retirement Plan Acknowledgement, front - this is the page new employees fill out
Retirement Plan Acknowledgement, back info only, you keep this page
TIAA-CREF new member 403(b) application - this is the form new employees fill out, but only if they don’t have access to a computer.  Online enrollment (instructions) is preferred and easier.
TIAA-CREF new member 457(b) application - only needed if you contribute the maximum in the 403b
TIAA-CREF name change
TIAA-CREF beneficiary change form; easy instructions to do it online
TIAA-CREF direct transfer
Fidelity new member application
Fidelity name change
Fidelity direct transfer
Fidelity 403(b) beneficiary change
Fidelity 457(b) beneficiary change
Withdrawing retirement within 32 days of leaving

Tuition Discount

Apply online for employee/spouse/child tuition discount