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MAP - Personal Medication Question Guide Form

The UFT Member Awareness Program provides this medication question guide form for you convenience when you visit your doctor. The form enables you to list all your medications, with dosage and frequency for easy review.

Medicare Part D Creditable Coverage Disclosure Notice

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.

Market Rate Application Form – Informal Providers

Moving forward, all informal providers will receive the standard 2007 market rate without having to apply. In order to receive the 2007 rate retroactively, informal providers must apply for it and attest that their cost of care has increased. Please...

Market Rate Application Form – Registered Family and Licensed Group Providers

Registered family and licensed group providers whose rates listed on file with ACS are not already higher than the 2007 market rate should use this form to apply to receive the new market rate moving forward and retroactively.

Training Record Form – Informal Providers

Informal providers should use this form to record any training sessions they attend. Informal providers who complete 10 or more hours of approved training in at least two different approved topics may be eligible to receive a higher, “enhanced”...

C-3.3: Limited Release of Health Information (HIPAA)

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

Transit Benefit Program Enrollment Form

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