Get UFT C-1259 2013-2023
L medical coverage School Telephone soc al ILLJ School or Bureau Sex SpouselDomestic Partner Social Security Number o ACTIVE MEMBER o RETIREE o COBRA PLEASE SUBMIT PRE-TREATMENT X-AAVS FOR NON-ROunNE EXTRACTIONS AND PREAND POST TREATMENT X-RAYS FOR ROOT MEMBER INFORMATION - See instructions on reverse side DENTAL FORM Refer Completed Claims and Questions to UFT Welfare Fund c/o Connecticut General Life Insurance Co. leM K D II 1-800-577-0576 SURGERY OR WHEN EXPENSES WIlL EXCEED 500 IN A 90 DAY PERIOD III Q Yes - Spouse/Domestic Partner UFT is a UFT Member therefore eligible for Special C. O. B. umro FEOERATD I Of TEACtiERS WElFARE RRtD lQO l* Z. N* EfICAIl FroEMTDH Of AA. O l CIGNA HcaltbCare Q PRE-TREATMENT ESTIMATE REQUIRED FOR INlAYS CROWNS* LAMINATE VENEERS BRIDGES DENTURES* PERIODONTAL o PAYMENT CLAIM CANAl* THERAPY I Birt date I Member Name Please Print Home Address City State se rity Zip Code i Telephone Do you have G*H. PO. Box 182531 Chattanooga TN 37422-7531 DYes 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 if claim is for Spouse/Domestic Partner or Dependent Child I. S otise/Domestic Partner. 8Irthda Is spouse/domestic partner covered by another Dental Benefits Plan other than UFTWF o Yes o No If yes. specify below. Company/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 DENTIST INFORMATION - See instructions on the back regarding the need for x-rays Dentist s Name please Print Street Address Taxpayer 10 II Ucense o Date of Prior Placement If prosthesis is this the initial placement 0 No If no. the reason for replacement DENOTE MISSING TEETH WITH AN X 115 this claim the result of Accident Injury 0 Yes 0 No Motor Vehicle Injury 0 Yes 0 No l PATIENT S NAME - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - i -------AGE Are radiographs enclosed If yes how many DVes Tooth or letter ONo Surtace Description of Service including materials used Date Service Performed Procedure Code I herllby certify thllllcourAcy of tho prll lrllAtmont Illitimlltlll lnd/or proC ld rlllllilnd if eomplotod the dliltelil of oompletion lllillitli d llbov i Was II pl 8 tl llfttment filled by llnother provldllr7 Q Ya C No Signed Dentist Oate C - 1259 5/13 1111111111 l1li1111 II TOTAL FEE CHARGED Fee. leM K D II 1-800-577-0576 SURGERY OR WHEN EXPENSES WIlL EXCEED 500 IN A 90 DAY PERIOD III Q Yes - Spouse/Domestic Partner UFT is a UFT Member therefore eligible for Special C. O. B. umro FEOERATD I Of TEACtiERS WElFARE RRtD lQO l* Z. N* EfICAIl FroEMTDH Of AA. O l CIGNA HcaltbCare Q PRE-TREATMENT ESTIMATE REQUIRED FOR INlAYS CROWNS* LAMINATE VENEERS BRIDGES DENTURES* PERIODONTAL o PAYMENT CLAIM CANAl* THERAPY I Birt date I Member Name Please Print Home Address City State se rity Zip Code i Telephone Do you have G*H. .
How It Works
How to fill out and sign uft welfare dental form online?
Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:
Are you searching for a fast and practical tool to fill out UFT C-1259 at an affordable price? Our platform offers you an extensive collection of templates that are available for submitting on the internet. It only takes a few minutes.
Keep to these simple instructions to get UFT C-1259 ready for submitting:
- Get the form you need in our collection of templates.
- Open the form in our online editing tool.
- Read through the guidelines to determine which info you will need to give.
- Select the fillable fields and include the necessary info.
- Put the date and insert your e-signature as soon as you fill in all of the fields.
- Look at the completed document for misprints and other errors. If you need to change some information, the online editor and its wide variety of tools are ready for your use.
- Download the completed template to your computer by clicking on Done.
- Send the electronic document to the intended recipient.
Filling out UFT C-1259 does not need to be complicated anymore. From now on simply cope with it from your home or at your workplace from your mobile or PC.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Video instructions and help with filling out and completing uft dental reimbursement form
We have the aim of making it easy for every American to fill out and finish Form without unnecessary hassle or frustration. Viewing the video guide listed below can help you work through each step of the workflow.
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
Keywords relevant to uft cigna dental form
USLegal fulfills industry-leading security and compliance standards.
#1 Internet-trusted security seal. Ensures that a website is free of malware attacks.
Guarantees that a business meets BBB accreditation standards in the US and Canada.
Highest customer reviews on one of the most highly-trusted product review platforms.