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Physician Statement Concerning Tobacco Usage and
Fitness to Participate in a Tobacco Cessation Program
INFORMATION FOR THE PHYSICIAN
As The University of Texas System (UT System) has a tobacco premium
surcharge for individuals enrolled in the UT SELECT or UT CONNECT
self-funded employee medical insurance plans. Plan members who
use tobacco products will be charged a tobacco usage premium
surcharge. Plan members can obtain an exemption from the surcharge
by providing a declaration the member has not used tobacco products
in the past sixty (60) days. In the alternative, a member that provides
a physician’s statement that ( due to a health factor, it would be
unreasonably difficult for the member to meet the requirements of
the program, but who participates in a UT System approved tobacco
cessation program or in some cases, a reasonable alternative program)
is eligible for a waiver of the premium surcharge. Members who have a
medical condition that makes it medically inadvisable for the member
to use a tobacco cessation program may also be eligible for a premium
surcharge waiver. This document must be completed each plan year.
For purposes of the program, “tobacco usage” includes, but not limited
to smoking cigarettes, cigars, pipes, 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
as is the use of all forms of smokeless tobacco, such as: chewing
tobacco, snuff, dip, or any other product that contains tobacco.
A description of the tobacco cessation program approved by UT System
is available at: www.utsystem.edu/offices/employee-benefits/
insurance/tobacco-premium-program
If you have questions please call (512) 499-4616 or email
benefits@utsystem.edu
PHYSICIAN’S STATEMENT CONCERNING TOBACCO USAGE
The following information pertains to:
PRINT MEMBER’S NAME (LAST, FIRST, MIDDLE) EMPLOYEE ID / BENEFITS ID (BID) DATE OF BIRTH
As the above-named member ‘s treating physician, it is my opinion that this individual has the following medical condition:
, that would make it unreasonably difficult for the member to cease
tobacco use at this time. However, it is my opinion that there is no medical reason that this member cannot to participate in the UT
System approved tobacco cessation program described above.
As the above-named member ‘s treating physician, it is my opinion that this individual has the following medical condition:
; (e.g., nicotine addiction) that would make it unreasonably difficult
for the member to cease tobacco use at this time. It is my further opinion that at this time the UT System approved tobacco cessation
program described above is not a reasonable alternative for the member.
As the above-named member ‘s treating physician, it is my opinion that due to the following medical condition,
, it is medically inadvisable for the member to cease tobacco use at
this time.
By signing this statement, I certify that the above information is true and correct. I understand that this form must be
completed each plan year for your patient to be eligible for the exemption.
PRINT PHYSICIAN NAME PHYSICIAN TAX ID NUMBER
PHYSICIAN SIGNATURE DATE
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