Forms for health benefits

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.