PAGE 1 of 3 ver.021819
Declaration of Tobacco Use or
Non-Tobacco Use Form
INFORMATION ABOUT THE TOBACCO PREMIUM PROGRAM
As part of its efforts to support the overall health and wellness of
UT SELECT Medical plan members, University of Texas System has
implemented a tobacco premium program surcharge to discourage the
use of tobacco.
Members enrolled in the UT SELECT Medical plan will pay a monthly
surcharge in addition to the premium normally charged for UT SELECT
Medical plan coverage of $30 per month if they use tobacco. All
members will be required to provide a declaration regarding their
tobacco use as a condition of enrollment in UT SELECT. New members
who use tobacco will begin to pay the additional charge on the first
of the month following enrollment. The Tobacco Premium Program
surcharge will be added to the UT SELECT premium that is deducted
from your paycheck. All subscribing members are required to submit
a declaration with regard to themselves and all of their covered
dependents regardless of whether they use tobacco or not.
Premium surcharges are based on three categories: Member $30 per
month; Spouse $30 per month, and Child(ren) $30 per month. The
premium surcharge for a family where any covered dependent child
uses tobacco is $30 regardless of whether other covered dependent
children do not use tobacco. The maximum premium surcharge is $90
per family per month.
Members must declare if they are tobacco users. A “tobacco user”
is defined by as a person who has used tobacco products within the
past sixty (60) days. The sixty days are from the day this declaration
is signed. Members who declare they are non-tobacco users must not
have used tobacco products within the pasty sixty (60) days from the
day this declaration is signed.
All types of tobacco products are included as part of the Tobacco
Premium Program, including, but not limited to: cigarettes, cigars, pipes,
all forms of smokeless tobacco (chewing tobacco, snuff, dip, or any
other product that contains tobacco), clove cigarettes and any other
smoking devices that use tobacco such as hookahs. E-cigarettes, which
contain nicotine, are also included under the tobacco premium program.
More information is available about this program at www.utsystem.
edu/offices/employee-benefits/insurance/tobacco-premium-
program
Please Continue and Sign on page 2 >
Declaration of Tobacco Use or Non-Tabacco Use Form | PAGE 2 of 3 ver.021819
DECLARATION OF TOBACCO USE OR NON-TOBACCO USE
By signing this form, I understand and agree that:
“Tobacco Products” includes but is not limited to: cigarettes, cigars, pipes, all forms of smokeless tobacco (chewing tobacco, snuff,
dip, or any other product that contains tobacco), clove cigarettes and any other smoking devices that use tobacco such as hookahs.
E-cigarettes are also included. “Tobacco User” is defined by UT System Office of Employee Benefits as a person who has used
tobacco products within the past sixty (60) days. The sixty days are from the day this certification is signed.
It is my obligation to submit an amended declaration if I or anyone else declared on this form to be a Non-Tobacco User uses
Tobacco Products. I also understand that failure to do so is a violation of the UT SELECT Medical plan rules and UT System policy.
I understand that all premium surcharges charges as a Tobacco User will be prospective. I further understand that if I or a dependent
subsequently cease to be a Tobacco User, and I submit an amended declaration changing a Tobacco User to a Non-Tobacco User, I
will not be refunded any part of the Tobacco User premium surcharges I have already paid.
By signing this statement, I acknowledge under the penalties of perjury, that the above are true and accurate statements.
The undersigned submits the following information about him or herself and any of his or her dependents enrolled in the UT
SELECT Medical plan:
Tobacco User Declaration: o No Tobacco Users o Subscriber o Spouse o Child(ren)*
* If any dependent child 16 years of age or older uses tobacco, check “tobacco user”. The tobacco premium surcharge is the same
regardless of how many children in the household use tobacco.
PRINT SUBSCRIBER’S NAME (Last, First, Middle) EMPLOYEE ID / BENEFITS ID (BID)
SUBSCRIBER’S SIGNATURE DATE
Please Continue to Instructions on page 3 >
Declaration of Tobacco Use or Non-Tabacco Use Form | PAGE 3 of 3 ver.021819
INSTRUCTIONS
This form must be signed and submitted to the subscriber’s institution HR/Benefits Office.
UT ARLINGTON
Office of Human Resources
P.O. Box 19176
Arlington, TX 76019
(817) 272- 5554
Fax: (817) 272-6271
benefits@uta.edu
UT AUSTIN
Human Resources
1616 Guadalupe St., Suite 1.408
Austin, TX 78701
(512) 471-4772 or
Toll Free: (800) 687-4178
Fax: (512) 232-3524
HRSC@austin.utexas.edu
UT DALLAS
Office of Human Resources
800 W Campbell Rd, AD 10
Richardson, TX 75080-3021
(972) 883-2221
Fax: (972) 883-2156
benefits@utdallas.edu
UT EL PASO
Human Resources Services
Administration Building, Rm 216
500 W University
El Paso, Texas 79968
(915) 747-5202
Fax: (915) 747-5815
hrs@utep.edu
UT HEALTH SCIENCE CENTER
HOUSTON
Human Resources
7000 Fannin, Suite 150
University Center Tower (UCT)
Houston, TX 77030
(713) 500-3935
Fax: (713) 500-0342
hr@uth.tmc.edu
UT HEALTH SAN ANTONIO
Office of Human Resources
7703 Floyd Curl Drive
San Antonio, TX 78229
(210) 567-2600
Fax: (210) 567-6791
ben-admin@uthscsa.edu
UT HEALTH EAST TEXAS (TYLER)
Office of Human Resources
11937 U.S. Highway 271
Tyler, TX 75708
(903) 877-7784
Fax: (903) 877-5394
benefits@uthct.edu
UT MD ANDERSON CANCER
CENTER
Human Resources Benefits
(713) 745-6947
Fax: (713) 745-7167
MyHR@mdanderson.org
Physicians Referral Service (PRS)
(713) 792-7600
Fax: (713) 794-4812
prsfacbensrvs@mdanderson.org
UT MEDICAL BRANCH AT
GALVESTON
Employee Benefits Services
2200 Market St., Suite 1.100
Galveston, TX 77550
(409) 772-2630, Option “0”
Toll Free: (866) 996-8862
Fax: (409) 772-2754
benefits.services@utmb.edu
UT PERMIAN BASIN
Human Resources
4901 East University
Odessa, Texas 79762
(432) 552-2752
Fax: (432) 552-3747
personnel@utpb.edu
UT RIO GRANDE VALLEY
Brownsville
Office of Human Resources
2395 West University Blvd.
Brownsville, Texas 78520
(956) 882-8205
Fax: (956) 882-6599
hr@utrgv.edu
Edinburg
Office of Human Resources
1201 West University Drive
Maryalice Shary Shivers
Building room 2.126
Edinburg, Texas 78539
(956) 665-2451
Fax: (956) 665-3289
hr@utrgv.edu
UT SAN ANTONIO
Human Resources
1 UTSA Circle
San Antonio, Texas 78249
(210) 458-4250
Fax: (210) 458-7890
hr@utsa.edu
UT SOUTHWESTERN MEDICAL
CENTER
Human Resources Benefits Division
5323 Harry Hines Blvd.
Dallas, TX 75390-9023
(214) 648-9830
Fax: (214) 648-9881
benefits@utsouthwestern.edu
UT SYSTEM ADMINISTRATION
Office of Human Resources
210 W. 7th Street
Austin, TX 78701
(512) 499-4587
Fax: (512) 499-4380
ohr@utsystem.edu
UT TYLER
Office of Human Resources
ADM 108
3900 University Blvd.
Tyler, Tx 75799
(903) 566-7234
Fax: (903) 565-5690
humanresources@uttyler.edu