If you need more information, call the Benefit Trust Fund office
(845) 562-7988
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Enrollment Form
Complete this form if you have changed your name or address. If you change your name due to marriage, please attach a copy of your marriage license.
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Non-Participating Provider Vision Claim Form
Out of Network vision provider form for reimbursement
![](http://newburghta.com/wp-content/uploads/child-tooth-missing-person-smile-face_t20_Xv88VV-scaled.jpg)
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Dependent Student Semester Verification Form
Complete this form, each semester, for your dependent post-secondary student.
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Proposed Orthodontic Treatment
Have your orthodontist complete this form before any treatment has begun.
![](http://newburghta.com/wp-content/uploads/close-up-care-teeth-health-braces-dental-dentistry-orthodontics_t20_WJxAe4-scaled.jpg)
Clarification Of Orthodontic Treatment
Have your orthodontist complete this form once banding is complete.
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Board of Trustees
Board of Trustees of the Newburgh Teachers’ Association Benefit Trust Fund
![](http://newburghta.com/wp-content/uploads/paperwork-doing-bills-or-filing-taxes-and-writing_t20_NQJBAN-scaled.jpg)