HIPAA Notice of Privacy Practices

Health Care
Qualifying Status Change ('Life Event') Form (must be completed in addition to enrollment forms when making any changes to your current medical/dental/flex plan)
Benefits Enrollment Form (Faculty/Staff)
Benefits Enrollment Form (UMMG Physicians)
Benefits Enrollment Form (Miller School of Medicine Residents)
Dependent Enrollment Form (Faculty/Staff)
Dependent Enrollment Form (UMMG Physicians)
Dependent Enrollment Form (Miller School of Medicine Residents)
Nonsmoking Certification
Spouse/Partner No Access Certification
Adult Dependent No Access Certification
Summary of Benefits & Coverages: Aetna Select 1
Summary of Benefits & Coverages: Aetna Select 2
Summary of Benefits & Coverages: Aetna HRA
Summary of Benefits & Coverages: Aetna HRA (Out of Area)
Flexible Spending Election Form
Short Term Disability Enrollment Form
Aetna Rx Home Delivery
FSA Healthcare Reimbursement Form (If you do not have Adobe Acrobat, you must print this form to complete it.)
FSA Dependent Reimbursement Form (If you do not have Adobe Acrobat, you must print this form to complete it.)
Aetna Medical Claim Form
Aetna Rx Claim Form
Delta Dental Claim Form
Aetna Precertification Rx Form

Domestic Partnerships
Certification of Domestic Partnership
Termination of Domestic Partnership
Domestic Partnerships Q&A

Beneficiary
Beneficiary designations must be completed at myUM.
Employees' Retirement Plan Spousal Consent Form
Employees' Retirement Plan Beneficiary Form

Retirement Savings Plan (RSP)
Please click here for steps to enroll.

Supplemental Retirement
Please click here for steps to enroll.

Tuition Remission
Graduate Tuition Remission Taxation Estimate
Spouse/Dependent Graduate Tax Estimate

Voluntary Benefits
Short-Term Disability Initial Claim Form
Short-Term Disability Follow-Up Claim Form
Voluntary Accidental Death and Dismemberment Application
Excess Life Enrollment Form
Long Term Care Enrollment Form (employee and spouse/domestic partner)
Long Term Care Enrollment Form (eligible family members)
Long Term Care Evidence of Insurability
Voluntary Benefits Cancellation Form