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...

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.

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.

You can choose a personal representative(s) to share your health information with by filling out this form.

You may authorize the UFT to use/disclose your protected health information by filling out this form.

For HIP subscribers only, use this In-Hospital Private Duty Nursing Claim Form for the UFT Welfare Fund to cover the costs, after a 72-hour deductible, of 80% of the usual and customary costs of in-hospital services provided by a registered nurse...

This price waiver form must be completed by both the member and his/her physician in cases where a brand rather than generic prescription is deemed medically necessary.

This form is for retired members who have elected a New York City optional rider or New York City health plan, or are covered under their spouse’s/domestic partner’s NYC health plan.

This form is for retired members who have elected a non-New York City optional rider for health insurance or prescription plan, or are covered under their spouse’s/domestic partner’s non-NYC health plan.

For HIP subscribers only, includes a section for member and physician to fill out. Please attach original, itemized, paid bill showing date and item purchased.