Legal referrals injury claim form

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.

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.

This application form is to be used only by pedagogical personnel who have received a regular appointment.

Complete this form and file it with your school payroll secretary within 10 days.

DOE lactation accommodation request form (LARF) for nursing mothers. See the current DOE lactation accommodation policy.

Use this form to claim out-of-pocket expenses related to your injury or illness.

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

Please complete this form if you would like to cancel the Electronic Fund Transfer (EFT) or Direct Deposit of one or both of the following: a) your monthly retirement allowance under the Qualified Pension Plan (QPP); or b) your monthly annuity...

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

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

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.

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"...

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.

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

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).

Please file this form only if you meet one or both of the following conditions: You are receiving Qualified Pension Plan (QPP) and/or Tax-Deferred Annuity (TDA) payments from TRS through Electronic Fund Transfer (EFT); and The account number at your...

DOE form to receive salary credit for prior work experience

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...

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...

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.

Use the forms in this package to report occupational exposure incidents. Exposure incident means a specific eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood or other potentially infectious materials that results...

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.

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.

You may authorize the UFT to use/disclose your protected health information by filling out this form.

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...

All pedagogical personnel may apply for a medical leave of absence without pay only when they have exhausted all of their Cumulative Absence Reserve (CAR) days. This application must be completed, signed and submitted to HR Connect for approval...

UFT membership application for all DOE titles except paraprofessionals. Print, complete and submit this application form only if you are not able to use the UFT's online enrollment form.

Pedagogues and paraprofessionals use this form to apply for a retirement leave of absence. For every two days in the employee’s sick bank, one day of terminal leave is granted. The form must be filed 30 days in advance of the leave. The leave can...