Benefits Forms

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Delta Dental - effective 4/1/08

Delta Dental's Welcome Page for UUP Members

Delta Dental Highlight Sheet

Delta Dental Claim Form

CIGNA Dental Forms

CIGNA Dental Claim Form (for claims prior to 4/1/08)


Other Benefits Forms

Important Phone Numbers
(Print and save as a handy reference)

Maintaining UUP Membership on Leave Without Pay

Benefit Trust Fund Privacy Notice

Benefit Trust Fund HIPAA Authorization Form
(For use or disclosure of Protected Health Information)

Benefit Trust Fund Change of Marital or Dependent Status Form
(For enrollment changes of dental and vision coverage)

Benefit Trust Fund Direct Payment Application Form
(Information and form for direct payment of dental and vision benefits)

Benefit Trust Fund Scholarship Application Form
(Information and an application form)

Benefit Trust Fund Student Verification Form
(Information and a student proof form)

Davis Vision Direct Reimbursement Claim Form

Laser Vision Reimbursement Claim Form