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 ONLYNew 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 request; documentation may be required.  Click here to see qualifying events. 

Also fill out the Dependent Verification for Insurance Coverage if you are covering any family members on your insurance.

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 2016 enrollment form (only for new hires 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
UMR Forms website to give a spouse or others access to your medical claims (select “Find a form”, then “Authorization For Release of Protected Health Care Information”)
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, AD&D change, drop or reduce Optional Life or Dependent Life coverage
Apply for Optional Life or Dependent Life online  if you are past your first 31 days of eligibility; or fill out this form online, print and mail to Standard.
Conversion application; Portability application  to 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 to access a portion of your life insurance now if diagnosed with a terminal illness
Claim-Waiver of Premium (contact our office about this form; only needed if employee is not eligible for Long Term Disability)


Drop Optional Long Term Disability or Optional Short Term Disability (or enroll if you are within your first month of eligibility)
Claim – Long Term Disability
 – ask for help from Human Resources to complete this claim
Short Term Disability claims are filed by phone, 1-888-641-7194
Application to convert to an individual Long Term Disability policy when your coverage as an employee ends (sorry, no option to continue Short Term Disability)

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 the front page, you keep the back Acknowledgements.  Indicate the % you want to contribute on a voluntary basis; do not include the 2% required contribution as that will be automatic (note that the required contribution will increase by 1% each year until it reaches 5% in 2020).

Report other employer retirement contributions in 2017

Withdrawing retirement within 32 days of leaving – we cannot sign off on your retirement distribution request without this form

TIAA online enrollment instructions  
TIAA name change
TIAA online beneficiary change instructions
TIAA transfer  (rollover another account to TIAA)

Fidelity online enrollment instructions
Fidelity online beneficiary change instructions
Fidelity direct transfer

Tuition Discount

Apply online for employee/spouse/child tuition discount