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Dental Claim Form Instructions
These instructions explain how to fill out your dental claim form either after treatment or for pre-treatment estimates for more complicated procedures such as periodontic surgery, bridges, crowns, inlays, dentures and other procedures that cost over...
Dental Enroll/Transfer Form
As a new member you are automatically enrolled in the Scheduled Benefit Plan. If you wish to enroll in one of the other UFT Welfare Fund dental options use this form. All other members and retirees who wish to transfer from one UFT Welfare Fund...
Dependent Child Affidavit
Fill out and have this form notarized for your dependent child to ensure coverage by the UFT Welfare Fund benefit plan.
Direct Access Dental Plan
This fully explains the benefits available under the UFT Welfare Fund Direct Access Dental Plan (SIDS – Self-Insured Direct Services) and includes a subscription form at the end.
Disabled Dependent Child Affidavit
Fill out and have this affidavit notarized to cover unmarried children over age 26 who cannot support themselves because of a mental illness, developmental disability, mental retardation or physical handicap under the UFT Welfare Fund Benefit Plan....
Drug Reimbursement Form for In-Service Members
Include all original pharmacy receipts with prescription detail clearly noted which must include the name, strength, quantity and price. Please attach to this form. Receipts must be mailed within 90 days from date of service. Reimbursement will be in...
Durable Medical Equipment Deductible Reimbursement Form - GHI-CBP Subscribers Only
For GHI-CBP in-service members only, the Welfare Fund will reimburse up to $100/year of the deductible for the purchase or rental of durable medical equipment, with this form and an original Explanation of Benefits (EOB) from GHI.
HIPAA: Privacy Practices Statement
Read this notice of privacy practices to understand how protected health information about you may be used and disclosed and how you can get access to this information.
HIPAA: Personal Representative Form (PR Form)
You can choose a personal representative(s) to share your health information with by filling out this form.
HIPAA: Protected Health Information Authorization Form (PHI Form)
You may authorize the UFT to use/disclose your protected health information by filling out this form.