Skip to main content
Full Menu

Forms for health benefits

Most of the forms below are PDF files. If you encounter any problems viewing PDFs on your computer, you may need to install the free Adobe Reader software.

PLEASE NOTE: The “Application For Age 26 Young Adult Coverage” form is no longer required by the UFT Welfare Fund. Members wishing to add a dependent under age 26 to their Welfare Fund coverage at no cost should use the Welfare Fund’s online Update Your Information (Change of Status) form.

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.

Complete a separate application for Young Adult Coverage for each dependent child between the ages of 26-29 for whom you are requesting coverage by the UFT Welfare Fund.

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.

Use this form to decline all Welfare Fund benefits for yourself and eligible dependents. You must sign this form and have it notarized.

Use this form to decline Welfare Fund dental and/or vision benefits for yourself and eligible dependents. You must sign this form and have it notarized.

Use this form to decline Welfare Fund benefits for your eligible dependents. You must sign this form and have it notarized.

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

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 $500 in a 90-day period.

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 dental plan to another can do so annually from Sept. 1 – Oct. 15, using this form. The new plan becomes effective Nov. 1.

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 schedule for a few services.