Forms for Health Benefits

Most of the forms below are PDF files. If you encounter any problems viewing PDFs on your computer, you may need to install the free Adobe Reader software.

PLEASE NOTE: The “Application For Age 26 Young Adult Coverage” form is no longer required by the UFT Welfare Fund. Members wishing to add a dependent under age 26 to their Welfare Fund coverage at no cost should use the Welfare Fund’s online Update Your Information (Change of Status) form.



  • Use this form to decline Welfare Fund dental and/or vision benefits for yourself and eligible dependents. You must sign this form and have it notarized.

  • After you have read the dental claim form instructions (below) you are ready to fill out the dental claim form as needed.

  • 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 $500 in a 90-day period.

  • 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 dental plan to another can do so annually from Sept. 1 – Oct. 15, using this form. The new plan becomes effective Nov. 1.

  • For Welfare Fund members who are using a non-participating dentist, your reimbursement will be according to this dental fee schedule; for those using a participating dentist, there will be no cost to the member except for co-pays listed in this schedule for a few services.

  • For UFT members in the Florida area, this is the Schedule of Benefits. When you use a UFT Welfare Fund participating dentist, you will be provided with the services listed in the Schedule of Covered Dental Expenses without charge except for those few services where a co-payment is required. Since usual and customary dental charges generally exceed the allowances, this represents an overall savings to you. If you use a non-participating dentist, you will be reimbursed according to this schedule.

  • 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.

  • Participating Dentist Program. Administered by SIDS.

  • If you or a member of your family who is covered by our dental benefits wish to use a Participating Dentist, select one from this Directory and call for an appointment.

Health Benefits


Other Benefits


  • 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 accordance with a Schedule of Allowances.

  • The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of our prescription drug benefit.

  • 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.

  • For retired members, this notice has information about your current prescription drug coverage with the UFT Welfare Fund and your options under Medicare’s prescription drug coverage. Please read carefully.

  • This is your Medicare Part D Reimbursement Claim Form, for retired members and their spouses/domestic partners.



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