Uft Welfare Fund Contact PDF Details

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.

QuestionAnswer
Form NameUft Welfare Fund Contact
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesuft dental, uft dental claim form, uft dental form pdf, uft dental form

Form Preview Example

Refer Completed Claims and Questions to:

UFT Welfare Fund c/o Connecticut General Life Insurance Co.

PO. Box 182531

Chattanooga, TN 37422-7531

1-800-577-0576

II

DENTAL FORM

 

UFT

 

 

 

 

umro FEOERATD!I Of TEACtiERS

 

 

WElFARE RRtD

CIGNA HcaltbCare

 

lQO,l. Z. N.:EfICAIl FroEMTDH Of AA.:O<l

 

 

Q PRE-TREATMENT ESTIMATE

o PAYMENT CLAIM

 

o ACTIVE

(REQUIRED FOR INlAYS, CROWNS. LAMINATE

PLEASE SUBMIT PRE-TREATMENT X-AAVS

 

MEMBER

VENEERS, BRIDGES, DENTURES. PERIODONTAL FOR NON-ROunNE EXTRACTIONS AND PRE-

o RETIREE

SURGERY OR WHEN EXPENSES WIlL EXCEED

AND POST·TREATMENT X-RAYS FOR ROOT

 

$500 IN A 90 DAY PERIOD)

 

CANAl. THERAPY

 

o COBRA

 

 

 

 

QYes - Spouse/Domestic Partner is a UFT Member therefore eligible for Special C.O.B.

SpouselDomestic Partner

Social Security Number

ILLJ

MEMBER INFORMATION - See instructions on reverse side

Ibゥイエセ、。エ・I I

 

Isoc;al ウ・セイゥエケi

 

Member Name (Please Print)

 

 

Sex

I I I I I

Home Address

City

 

State

Zip Code

Telephone #

 

 

 

 

 

(

)

School or Bureau

ISchool Telephone #

IDo you have G.H.L medical coverage?

 

 

 

 

{

)

DYes

0

No

 

Name and Address of Other Company/Organization Providing Dental Benefits under which you are covered

 

 

PATIENT INFORMATION

 

 

 

 

 

 

Patient Name (Please Print)

 

Relationship to Member

 

 

 

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 #

()

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)

Date

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 x-rays)

Dentist's Name (please Print)

 

 

IUcense#

 

Taxpayer 10 II

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

City

State

Zip Code

Telephone II

 

 

 

 

 

 

 

(

)

 

 

If prosthesis, is this the initial placement?

 

 

 

 

 

Date of Prior Placement

o Yes 0 No If no. the reason for replacement

 

 

 

 

 

 

 

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

DVes ONo

 

 

Motor Vehicle Injury

0

Yes 0 No

 

l ----------------- ' ---------------------- i

 

PATIENT'S NAME

 

 

 

AGE:

 

 

 

Tooth #

Surtace

Description of Service

 

Date Service

Procedure

 

Fee

 

or letter

(including materials used)

Performed

Code

 

 

 

 

 

(

(

(

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

 

 

TOTAL FEE

Signed {Dentist)

Oate

CHARGED

C - 1259 (5/13)

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