Get Notice Of Personal Information The Following Notice Is Provided In ... - Utdallas

This guide provides comprehensive instructions on completing the Notice of Personal Information form associated with the University of Texas System. It aims to assist users in understanding each component of the form and how to submit it successfully.

Follow the steps to fill out the form correctly.

1. Begin by clicking the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Review the introductory notice carefully. It outlines your rights regarding personal information collected by the University of Texas System Administration as per the Texas Government Code.
3. Fill in your name in the 'Employee’s Name' field and ensure it is accurate to avoid discrepancies.
4. Enter the component name associated with your insurance plan in the corresponding field.
5. Provide your social security number in the section designated for it, ensuring that it is entered accurately for identification purposes.
6. Input the contact information for your component, including the phone number and fax number, if applicable.
7. Indicate the insurance plan you are applying for from the provided options.
8. Complete the Employee’s Certification section. Certify that the dependent meets all the necessary conditions by providing their name and date of birth.
9. Sign and date the Employee’s Certification. Your signature confirms that the information is true and correct.
10. In the Attending Physician’s Statement, provide details about the dependent’s physical or mental handicap, including date of onset and any known causes.
11. The physician must sign and date the statement. Attach any additional medical information that supports the dependent’s condition as needed.
12. Once all fields are completed and verified for accuracy, save your changes, and proceed to download, print, or share the form as required.

Complete your Notice of Personal Information form online today for a smoother process.