
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....
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the UFT C-1259 online
The UFT C-1259 form is essential for healthcare claims related to dental services for eligible members. This guide provides a clear and supportive approach to help users effectively complete the form online.
Follow the steps to accurately fill out the UFT C-1259 online.
- Click the ‘Get Form’ button to obtain the form and open it in your preferred online document editor.
- Begin by filling out the member information section. Enter your full name, home address, city, state, zip code, and telephone number. If applicable, provide your social security number.
- Indicate your relationship status by selecting either 'Active Member', 'Retiree', or 'COBRA' as appropriate.
- In the patient information section, provide the patient’s name and relationship to the member.
- If the claim is for a spouse or domestic partner, fill in their details, including their name, birthday, and social security number. Indicate whether they have coverage under another dental benefits plan.
- Provide any required information about additional dental benefits from other companies or organizations.
- In the authorization section, sign the form authorizing the release of relevant information regarding the claim.
- For dental service information, complete the Dentist Information section with the dentist's details including name, address, and telephone number.
- Clearly indicate the services rendered, including the procedure code, and whether x-rays are enclosed.
- Finally, review all completed sections for accuracy and clarity before saving changes, downloading, printing, or sharing the form.
Complete the UFT C-1259 online to ensure timely processing of your dental claims.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
by T Zhang · 2025 — To investigate the effects of an 8‐week standardized computerized...
Lemma 2 of P is a cuff and I is a non erupty proper (uf) initial segmet off, then Q has...
LIMITED'I3NO YEAR WARRANTY ON CRAFTSMAN RIDING EQUIPMENT PARTS. For two (2) years from the...
Get answers to your most pressing questions about US Legal Forms API.
When did the NYC teacher contract expire?
The union's contract expired in September 2022 and their last raise was in May 2021.
Do NYC teachers get FMLA?
If eligible, teachers may apply for leave under the federal Family Medical Leave Act (FMLA), which provides up to 12 weeks of health benefits, commencing with the first consecutive absence, during maternity leave and childcare leave.
How much will NYC DOE teachers make in 2026?
Starting salaries for New York City teachers will increase to $72,350 by 2026 under the United Teachers Federation's newly ratified contract. That's 18.5% more than the current starting salary of $61,070.
What is the tentative contract for the UFT DOE?
This agreement will cover approximately 120,000 municipal employees, bringing the total workforce under contract to approximately 67 percent. The tentative agreement is retroactive, beginning on September 14, 2022, and expires on November 28, 2027.
What is the new contract for teachers in NYC?
Under the new contract, the maximum salary for teachers will rise to $151,271 by 2026. That means it will take teachers eight years to make over $100,000, instead of the current 15 years.
Did the UFT contract pass?
UFT members overwhelmingly approve new contract.
Did the new UFT contract pass?
UFT members overwhelmingly approve new contract.
When did the last UFT contract expire?
On Monday, the United Federation of Teachers (UFT) ratified a five-year contract covering nearly 200,000 public school workers across New York City. The contract, which will last until November 2027, went into effect immediately and is retroactive to September 2022 when the previous contract expired.
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.