Welfare Fund Forms

Most Welfare Fund forms are in PDF format. To download a free copy of Adobe Reader, click here.

Enrollment Form

Use this online form to enroll in the UFT Welfare Fund.

Change of Status Form

Use this online form to make changes to your name, update your mailing address, update your family profile including dependents and beneficiaries.

Anesthesia Benefit Claim Form - HIP Subscribers Only (30.5KB)

HIPAA: Privacy Practices Statement (57.3KB)

HIPAA: Personal Representative Form (PR Form) (16.2KB)

HIPAA: Protected Health Information Authorization Form (PHI Form) (32.4KB)

Dental Schedule Effective 07/01/06 (4.2KB)

Dental Claim Form Instructions (54.3KB)

Dental Claim Form (52.3KB)

Dental Enroll/Transfer Form (61.9KB)

Dependent Child Affidavit (25.2KB)

Dependent Student Certification Form (33.6KB)

Direct Access Dental Plan

UFT Direct Rx Access Enrollment Letter

UFT Direct Rx Access Enrollment Application

UFT Direct Rx Access Terms & Conditions

Direct Drug Reimbursement Form (27.7KB)

Disabled Dependent Child Affidavit (32.1KB)

Durable Medical Equipment Deductible Reimbursement Form (32KB)

Mandatory Generic Price Waiver Form (14.7KB)

Medicare Part D Creditable Coverage

Medicare Part D Reimbursement Claim Form

Optional Rider Claim Form For NON-NYC Health Insurance Plans

Optional Rider Claim Form For NYC Health Insurance Plans

Optional Rider Claim Questionnaire

Prescription Appliance and/or Medical Equipment Claim Form - HIP Subscribers Only (28.3)

Pre-Office Visit Form

Personal Medication Question Guide Form

Speakers Bureau Request Form