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Forms for supplemental

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.

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.

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.

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.