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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.

  • For UFT members in the Florida area, this is the Schedule of Benefits. When you use a UFT Welfare Fund participating dentist, you will be provided with the services listed in the Schedule of Covered Dental Expenses without charge except for those few services where a co-payment is required. Since usual and customary dental charges generally exceed the allowances, this represents an overall savings to you. If you use a non-participating dentist, you will be reimbursed according to this schedule.

  • 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.

  • Participating Dentist Program. Administered by SIDS.

  • We are pleased to announce the optical providers in this directory have affiliated with our Optical Benefit Program. Stamped and validated Optical Benefit Certificates will be honored by any of them.

  • 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. (Note: you must first obtain a “Certificate of Disability” from your basic health care carrier. Include a copy of the letter of approval of disability from your health care carrier with your Welfare Fund affidavit.)

  • 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 accordance with a Schedule of Allowances.

  • For GHI-CBP 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) from GHI.

  • 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.

  • If you or a member of your family who is covered by our dental benefits wish to use a Participating Dentist, select one from this Directory and call for an appointment.

  • You can choose a personal representative(s) to share your health information with by filling out this form.

  • 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 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 from the fourth through the 60th day of nursing care.

  • 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.

  • 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.

  • This form, provided by the UFT’s Member Awareness Program can help you be sure to cover all necessary topics when you visit your doctor.

  • 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.

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

  • 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.

  • 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.

  • This directory should be a valuable source of information to survivors or executors designated to handle the estate of a deceased employee.

  • For HIP subscribers only, includes a section for member and physician to fill out. Please attach original, itemized, paid bill showing date and item purchased.

  • For UFT Chapter Leaders: Do you and your co-workers want to understand your Welfare Fund benefits better? By filling out this form you can request a Welfare Fund representative to come to your school and provide an overview of the benefits, with a question and answer period.

  • Summary comparison of health plans for employees and those retirees not eligible for Medicare.

  • Step Therapy is a program especially designed for people who take prescription drugs regularly to treat ongoing medical condition(s). The program is a new approach to getting you and your family the prescription drugs you need.

  • The Affordable Care Act requires group health plans to provide a Summary of Benefits and Coverage (SBC) to plan participants so they may better understand their coverage. In compliance with this law, the UFT Welfare Fund has completed an SBC regarding the essential benefit we provide, our prescription drug plan.