Over 65 Retiree Enrollment Packet

This packet includes several files to help you enroll in the PFT Health & Welfare Funds Programs. Please upload the completed forms to our secure upload portal or UCCI per the instructions on the letter.

• Retiree Letter - Over 65
• PFTHW Retiree Benefit Application (Writable)
• Retirement Prescription Application (Writable)
• United Concordia Enrollment/Change Form
• NVA Vision Benefit Summary

PDF • 1.39 MB

Under 65 Retiree Enrollment Packet

This packet includes several files to help you enroll in the PFT Health & Welfare Funds Programs. Please upload the completed forms to our secure upload portal or UCCI per the instructions on the letter.

• Retiree Letter - Under 65
• PFTHW Retiree Benefit Application (Writable)
• Retirement Prescription Application (Writable)
• NVA Vision Benefit Summary
• United Concordia Enrollment/Change Form

PDF • 1.39 MB

IBX PDP Application

Medicare Prescription Drug Plan Employer Group Enrollment and Change Form

PDF • 172 KB

PFT Health & Welfare Enrollment Card (PDF)

Fill out this form to enroll in the PFT Health & Welfare Funds Vision, Prescription and Dental benefit programs.

PDF • 164 KB

PFT Basic Vision Form (PDF)

Fill out this form to be reimbursed for your out-of-network vision services.

PDF • 190 KB

Notice of Change (PDF)

Use this form to change your address or name, or add or remove a dependent.

PDF • 277 KB

Summary Plan Description (PDF)

Philadelphia Federation of Teachers Health and Welfare and Legal Services Fund Summary of Benefits

PDF • 797 KB

Health Advocate Services Brochure (PDF)

PFT Health & Welfare Fund Health Advocate Services provide personalized support to help you navigate healthcare decisions, understand your benefits, and resolve billing issues.

PDF • 4.3 MB

Medicare & You 2026 Handbook

The official U.S. government Medicare handbook for 2026.

PDF • 4.9 MB

Beyond The Established Norms: A New Kind Of Union Activism (PDF)

Learn about the AFT's approach to union-led professional development.

PDF • 5.4 MB

HIPAA Authorization Form

Health Insurance Portability and Accountability Act Authorization Form

PDF • 729 KB

HIPAA Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

DOC • 20 KB

Costco Mail Order Packet

Traditional Mail Order service PATIENT PROFILE FORM

PDF • 193 KB

Active CapitalRx Reimbursement

Prescription Drug Claim Form

PDF • 193 KB

Nations Hearing Info

A Hearing Aid Benefit that Improves Member's Health and Wellness

PDF • 193 KB

UCCI Dental Out of Network Reimbursement Form

Member Dental Claim Form

PDF • 193 KB

Your NVA Vision Benefit Summary

National Vision Administrators, L.L.C.

PDF • 193 KB