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.


TIP:  Verify your benefit change has been approved and keyed into SAP.

1. Log into Employee Self Service.
2. Click on Benefits and Payment, then Participation Overview.
3. Change Show Participation Overview as of date to a future date,  the date your change should take effect.
4. Click Go.
5. Click on a particular plan.  It defaults to the one at the top, but you can click on any plan.
6. Go to the bottom and click Show Participation Details.
8. If you want to do this for each benefit plan, click Back and select another plan.

TIP:  View your benefits statement if you’re not sure what you have now.

The Benefit Statement option in ESS differs from Participation Overview because it shows all benefit plans, even the ones you don’t have.  Here’s how to view your Benefits Statement:

1. Log into Employee Self Service.
2. Click Benefits and Payment.
3. Click UAMS Benefits Statement.
4. Use the scroll bar or Page Up/Down keys to view each page.
5. You can only view your statement in ESS.    If you prefer a printed copy, ask your department SAP person to assist you (SAP transaction ZHRESSBENSTMT).   Or you can visit our HR Employees Services office to request a copy.


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. 

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

Medical enrollment form
Dental enrollment form
Vision enrollment form
Form to change Life, LTD or AD&D coverage
(if adding or increasing coverage, EOI form may be required)
EOI (Evidence of Insurability) form 
(for current employees to add or increase Life, Optional LTD; not needed for AD&D changes)
Flexible Spending Account enrollment form


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
Life claim
Accelerated Life Claim
(access half of your life insurance now if you are diagnosed with a terminal illness)
Life conversion application and rates
Life portability applicationportability rates

Disability, Accidental Death & Dismemberment

Long Term Disability claim
Accidental Death & Dismemberment claim

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 20142015 form
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

Tuition Discount

Tuition discount form – employee
Tuition discount form – spouse or child
State of Arkansas student consent - UALR
State of Arkansas student consent  - other campuses