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Get UFT Welfare Fund's Dental Enrollment/Transfer Form 2017-2024

WELFARE United Federation of Teachers FUND 52 Broadway New York New York 10004 212 539-0500 DENTAL ENROLLMENT/TRANSFER FORM I choose D UFT Welfare Fund Scheduled Benefit Plan D Dentcare HMO D UFT Florida Dental Discount Plan permanent Florida residents only. Plan o Only one dentist may be selected for the entire family. o Relationship arne include last name if different from your last name Birth Date Mo/DayNr Sex Provider Name and Code umber Must be completed if selecting Dentcare HMO Spouse Child Upon completion of the Enrollment/Transfer Form please sign and mail it to the UFT Welfare Fund at the address aboveAttention DENTAL ENROLLMENT. D Retiree D Pre- 70 Retiree D COBRA Social Security Number Last Name First Name Middle Initial City State Home Street Address Work Phone Zip Code Marital Status D Single D Married D Widowed Divorced Home Phone Must complete D Domestic Partner Spouse/Domestic Partner s SS / / Is spouse/domestic partner a UFT member DYes D 0 Are you covered for dental benefits by another group plan or government agency DYes D No If yes name of other company/organization providing benefits INSTRUCTIONS If you selected Dentcare HMO Fill in name and code number the number which precedes name of the Dentist you have selected from the Directory of Participating Providers. Members that elect to participate in this plan are not eligible to receive any other dental benefits from the UFT Welfare Fund* Membership Status check one only D Employee Reason for submission D ew hiret D Transfer Period D Pennanent move in or out of an area* t tDate of event // Must be submitted within 31 days of event. o You may select a different dentist for each family member within the Dentcare Plan* o If you only enter one Provider Code all family members will automatically be enrolled in that office. o Benefits are only available at your selected participating dental office. o Fill ill name and code number from the Directory ofParticipating Providers for the OFT Florida Dental Discount. o You may select a different dentist for each family member within the Dentcare Plan* o If you only enter one Provider Code all family members will automatically be enrolled in that office. o Benefits are only available at your selected participating dental office. o Fill ill name and code number from the Directory ofParticipating Providers for the OFT Florida Dental Discount.

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