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OP 505: Request for Reimbursement of Medical Expenses
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.
Application for Layoff Seniority Credit for Prior Paraprofessional Service
This application form is to be used only by pedagogical personnel who have received a regular appointment.
WCD-23: Employee’s Notice of Injury
Complete this form and file it with your school payroll secretary within 10 days.
DOE lactation accommodation request form (LARF) for nursing mothers
DOE lactation accommodation request form (LARF) for nursing mothers. See the current DOE lactation accommodation policy.
Who is General Vision Services (GVS)?
For years, GVS has served as the third-party administrator for the Welfare Fund’s optical program, providing services such as claim processing. GVS will now also maintain new resources such as the program's website and mobile app. Their dedicated UFT...
C-257: Expense Reimbursement Form
Use this form to claim out-of-pocket expenses related to your injury or illness.
Medicare Part D Reimbursement Claim Form
This is your Medicare Part D Reimbursement Claim Form, for retired members and their spouses/domestic partners.
What is the HCFSA Program/Flexible Spending Account and how can it help with medical expenses? What is this?
The HCFSA is a flexible spending account for health care expenses. Here is how the HCFSA Program works: First, you contribute before-tax dollars into your HCFSA account via automatic payroll deductions. Next, in order to receive reimbursement, you...
TRS BK19: EFT/Direct Deposit Cancellation Request Form
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...
Dental Claim Form
After you have read the dental claim form instructions (below) you are ready to fill out the dental claim form as needed.
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.
Optional Rider Claim Form - NYC Health Insurance Plans
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.
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: Employee’s Claim
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.
Comprehensive Injury Report
This form details the nature of your injuries. It should be turned in to your principal within 24 hours of your accident or illness.
UFT increases Welfare Fund benefits
The UFT is enhancing its Welfare Fund optical benefit and hearing aid benefit for in-service members and retirees effective March 1, 2022.
Durable Medical Equipment Deductible Reimbursement Form - NYCE PPO in-service subscribers only
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).
TRS BK11: Account Number Change Form for Electronic Fund Transfer
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...
Your Health & Wellness
Members of the Family Child Care Providers chapter have access to a wide range of health and wellness benefits and services at no additional cost. See each health program below for more details.
DOE form to receive salary credit for prior work experience
DOE form to receive salary credit for prior work experience
Participating Panelist Program
Information on your eligibility for benefits will be available not only to you and your eligible dependents, but also to optical service providers, making it easier to schedule appointments and use your benefits for covered services.
Dental Claim Form Instructions
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...
Join the Union!
Enroll online to become a member of the UFT and tap into powerful support and benefits.
C-2: Employer’s Report
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...
Optional Rider Claim Form - Non-NYC Health Insurance Plans
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.
Bloodborne Pathogens Exposure Incident Package
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...
Plan details and coverage
Coverage for eligible members begins on their first day of employment, provided the member has enrolled in a timely manner.
Mandatory Generic Price Waiver Form
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.
C-4: Physician’s Report
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.
HIPAA: Protected Health Information Authorization Form (PHI Form)
You may authorize the UFT to use/disclose your protected health information by filling out this form.
Can I go to an optician not listed on the UFT Welfare Fund panel?
Yes, however it is to your advantage to use a participating provider. First, you can take advantage of additional discounts our panelists provide. Second, if you have a problem, the UFT Welfare Fund will help resolve any issues. If you use a non...
Drug Reimbursement Form for In-Service Members
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...
OP 160: Leave of Absence Without Pay
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...