Uft Welfare Fund Contact Form is now available on the website. This form can be used to contact the welfare fund for any questions or concerns that you may have. The welfare fund is dedicated to providing financial assistance to UFT members and their families in times of need. Please note that all requests for assistance must be made through this form. Thank you for your cooperation.
Below is the data in regards to the PDF you were seeking to complete. It will show you how much time it will need to fill out uft welfare fund contact, what parts you need to fill in and some further specific details.
| Question | Answer |
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| Form Name | Uft Welfare Fund Contact |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | uft dental, uft dental claim form, uft dental form pdf, uft dental form |
Refer Completed Claims and Questions to:
UFT Welfare Fund c/o Connecticut General Life Insurance Co.
PO. Box 182531
Chattanooga, TN
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DENTAL FORM |
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UFT |
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umro FEOERATD!I Of TEACtiERS |
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WElFARE RRtD |
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CIGNA HcaltbCare |
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lQO,l. Z. N.:EfICAIl FroEMTDH Of ｾ AA.:O<l |
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o PAYMENT CLAIM |
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o ACTIVE |
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(REQUIRED FOR INlAYS, CROWNS. LAMINATE |
PLEASE SUBMIT |
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MEMBER |
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VENEERS, BRIDGES, DENTURES. PERIODONTAL FOR |
o RETIREE |
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SURGERY OR WHEN EXPENSES WIlL EXCEED |
AND POST·TREATMENT |
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$500 IN A 90 DAY PERIOD) |
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CANAl. THERAPY |
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o COBRA |
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QYes - Spouse/Domestic Partner is a UFT Member therefore eligible for Special C.O.B.
SpouselDomestic Partner
Social Security Number
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MEMBER INFORMATION - See instructions on reverse side |
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Isoc;al ｳ･ｾｲｩｴｹi |
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Member Name (Please Print) |
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Sex |
I I I I I |
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Home Address |
City |
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State |
Zip Code |
Telephone # |
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School or Bureau |
ISchool Telephone # |
IDo you have G.H.L medical coverage? |
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DYes |
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No |
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Name and Address of Other Company/Organization Providing Dental Benefits under which you are covered |
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PATIENT INFORMATION |
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Patient Name (Please Print) |
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Relationship to Member |
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SPOUSE/DOMESTIC PARTNER INFORMATION - (Required
Spouse/Domestic Partner Name (please Print)
Is spouse/domestic partner covered by another Dental Benefits Plan other than
Name and Address of Other Company/Organization Providing Dental Benefits
if claim is for Spouse/Domestic Partner or Dependent Child)
I.ｓｾｯｴｩｳ･Ｏｄｯｭ･ｳｴｩ｣ Partner I ISpouselDomestic Partner Social Security II
. . Ｘｉｲｴｨ､｡Ａｾ .' I II I I I I I I I
UFTWF? o Yes o No If yes. specify below.
ICompany/Organization Telephone #
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AUTHORIZATION (Authorization to release information must be signed or payment will not be made)
To Release Information: I have reviewed the following treatment plan. I authorize release of any and all information relating to this claim.
Signed (Patient or Parent if Minor) |
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To Assign Benefits: I hereby authorize payment directly to the below named dentist of the benefits otherwise payable to me. I understand I am financially responsible to the dentist for charges not covered by this assignment. This authorization is invalid unless the TAX 10 # of the provider is given below.
Signed (Member)Date
DENTIST INFORMATION - (See instructions on the back regarding the need for
Dentist's Name (please Print) |
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IUcense# |
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Taxpayer 10 II |
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Street Address |
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City |
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Zip Code |
Telephone II |
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If prosthesis, is this the initial placement? |
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Date of Prior Placement |
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o Yes 0 No If no. the reason for replacement |
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DENOTE MISSING TEETH WITH AN "X" |
Are radiographs enclosed? If yes, how many? 115 this claim the result of: Accident Injury 0 Yes |
0 No |
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DVes ONo |
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Motor Vehicle Injury |
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Yes 0 No |
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PATIENT'S NAME |
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AGE: |
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Tooth # |
Surtace |
Description of Service |
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Date Service |
Procedure |
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Fee |
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or letter |
(including materials used) |
Performed |
Code |
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I herllby certify thllllcourAcy of tho prll'lrllAtmont Illitimlltlll!lnd/or ｰｲｯｃＨｬ､ｾｲｬｬｬｬｬｩｬｮ､Ｌ if eomplotod, the dliltelil of oompletion !lllillitli!d llbov!i, Was II pl'8>tl'llfttment filled by llnother provldllr7 Q Ya C No
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TOTAL FEE |
Signed {Dentist) |
Oate |
CHARGED |
C - 1259 (5/13)