This form is used by school nurses and occupational and physical therapists.

Although the cost of anesthesia for hospitalization, emergency illness or accidental injury should be covered in full by HIP/HMO, the Welfare Fund will pay 80% of reasonable, usual and customary charges when not covered by HIP/HMO.

Members on an approved Child Care Leave who are currently covered by the UFT Welfare Fund are eligible to receive extended UFT Welfare Fund benefits for up to a maximum of six (6) consecutive months for the birth or adoption of a child.

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...

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...

Fill out and have this form notarized for your dependent child to ensure coverage by the UFT Welfare Fund benefit 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.

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...

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

This form is used by all pedagogues to apply for medical certification for absence up to 20 consecutive school days, for requests to borrow sick days, for excuse of absence due to children’s diseases, and for injury in the line of duty claims. Rules...

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.

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.