Fill - Free fillable Declaration of Tobacco Use or Non-Tobacco Use Form PDF form

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

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