General Benefits Forms
- Life Conversion Application
- Life Portability Application
- Long Term Disability Conversion Application
Benefits Rates
Medical Insurance
- Authorization for Release of Information
- Medical Benefits Plan Nondiscrimination Statement
- Medical Claim Form
- Medical Plans Comparison Summary
- Prescription Drug Formulary
- Prescription Benefits Summary
- UAMS SmartCare FAQ
- UAMS Smartcare Provider Search
- UA Pre-authorization List (Medical Insurance)
- UA Pharmacy Appeal Form
- UMR Authorization for Release of Information
- UMR Provider Search
Arkansas Blue Cross and Blue Shield Dental
Vision Insurance
Flexible Benefit Plan
- FSA Claim Form (Dependent Care and Health Care)
- FSA Debit Card (Employee Guide)
- FSA Debit Card FAQ
- FSA Debit Card (General Information)
- FSA Direct Deposit Informational Flyer
- FSA Direct Deposit Authorization Form
- FSA Expense List
- FSA Letter of Medical Necessity
- FSA Worksheet
- FSA $500 Carryover Announcement
- FSA $500 Carryover FAQ
Summary of Plan Documents (SPD)
- Accidental Death and Dismemberment
- Basic and Optional Long Term Disability Group Insurance
- Basic Life Group Insurance Plan
- Dental Benefit Plan
- Flexible Spending and Health Savings Plan
- Optional and Dependent Life Group Insurance Plan
- University of Arkansas Retirement Plan
- University of Arkansas Medical Benefit Plan
Worker Compensation
- Injury Incident Report – No Medical Treatment Required
- Mileage Reimbursement Form
- Workers’ Compensation Procedures
Catastrophic Leave
- Applying for Catastrophic Leave
- Catastrophic Leave Recipient Application
- Catastrophic Leave Liability Agreement
- Physician Certification Form
- Catastrophic Leave Dependent Child Certificate
Family and Medical Leave
- FMLA Request Packet
- FMLA Request Form
- FMLA Procedures Acknowledgement Form
- Employee Rights Under the FMLA
- Genetic Information Non-Discrimination Act (GINA) of 2008
- Certification for Health Care Provider – EMPLOYEE (WH-380-E)
- Certification for Health Care Provider – FAMILY MEMBER (WH-380-F)
- Certification for Qualifying Exigency for MILITARY Family Leave – (WH-384)
- Certification for Serious Injury or Illness of Current Service Member – (WH-385)
- Certification for Serious Injury or Illness of Current Service Member- (WH-385-V)
- Certification for Adoption or Foster Placement
Leave Without Pay
- For more information regarding Leave Without Pay, please contact the Leave Administrator at 501-916-5709.
Classification/Compensation
- Concurrent Employment Form
- Concurrent Employment Request Form General Instructions
- Concurrent Employment Request Form Detailed Instructions
- Provisional Position Request Form – FY 24
- Hourly Position Classification Form
- Job Description Template
- Position Reclassification-Salary Adjustment Request Form
- Position Reclassification-Salary Adjustment Request Instructions
Payroll
- Visit the Payroll Office website for other payroll forms.
General
- ADA Accommodation Form
- ADA Accommodation Instructions
- Conflict of Interest Form
- Employee Counseling/ Disciplinary Form
- Employee Name/Address Change Form
- Exit Clearance Packet
- Request for Reasonable Accommodation for Religious Observance Form
- HR Guest of State
- Tuition Waiver Form – Employee
- Tuition Waiver Form – Spouse/Dependent
