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.

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....

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 NYCE PPO 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).

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.

For 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 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.

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...

Office of School Health Time Report for Nurses.

Save more than $200 each year in taxes by participating in the city’s TransitChek program.

This form allows health care providers who have treated your previous injuries to release information to your employer’s workers’ compensation insurer.

Form and instructions from the DOE Science Safety Manual.

This form for Lab Specialists is taken from the DOE Science Safety Manual.

If there is equipment in your school that is unrepairable, not cost-effective to repair, educationally inappropriate, or a safety hazard, complete this form to have the equipment removed.

Use this form to document a hazardous chemical exposure incident in your school. Parts I, II, and III of the form are included.

Especially for Lab Specialists. Use Page 1 to document the presence of mercury in a science room.

Extended Session Teacher/Student Ration Fact Sheet

This form details the nature of your injuries. It should be turned in to your principal within 24 hours of your accident or illness.

Use this confidential form to notify the UFT School Safety Department if you have been the victim of an incident and/or injury. Or fill out the online incident report form.

The DOE will reimburse you up to $500 per school year for stolen or destroyed property such as loss or damage to personal clothing and personal accessories. For reimbursement of eyeglasses damaged in assault cases, use form OP 505G.

Once line-of-duty status has been approved, you can use this form to request reimbursement for out-of-pocket medical expenses to a maximum of $1,500.

Workers’ compensation intake form for Paraprofessionals, School Nurses, Occupational and Physical Therapists:

The employer is required to fill out this report within 10 days to notify the Workers’ Compensation Board of your work-related injury or illness. You should not participate in filling out this form. See the C-2: Employer's Report - Filing Procedure...

You must fill out this form to initiate your Workers’ Compensation claim. You should retain one copy, file a second with the Board, and provide a third to your legal representative.

Your doctor must fill out this form at regular intervals — usually every 4-6 weeks — during your convalescence. It is used to determine your level of benefits — so it is very important that your doctor fills it out carefully.