STATE OF NEW YORK 
EMPLOYEE BENEFITS DIVISION 
DEPARTMENT OF CIVIL SERVICE 
THE STATE CAMPUS 
APPLICATION FOR WAIVER OF PREMIUM 
ALBANY, NEW YORK 12239 

This is the application for a waiver of health insurance contributions because of total disability. Any expenses incurred solely for obtaining the attending physician's statement on this application is not a covered medical expense. If you have questions regarding this application for waiver of premium, contact your agency Health Benefits Administrator.


NOTE: 

Enrollees on Family Medical Leave of Absence qualify to apply for a waiver of premium. An employee who is receiving short-term disability benefits under the New York Income Protection Plan is not eligible for a Waiver of Premium. Review your NYSHIP General Information Book to see if you may qualify for a waiver of premium.


ALL SECTIONS MUST BE COMPLETED IN FULL 

Instructions: 
	� Employee completes Part A 
	� Agency completes Part B 
	� Physician completes Part C and mails form directly to New York State 
	� Department of Civil Service, Employee Benefits Division, at the above address. 
	� Employee Benefits Division completes Part D 

PART A 
(To be completed by Employee.) 

PLEASE PRINT OR TYPE 

Name _________________________ 

Home Address__________________ 

ID Number_____________________ 

City__________________________ 

State_____ ZIP Code___________


PERSONAL PRIVACY PROTECTION LAW NOTIFICATION 


This information is being requested pursuant to Section 163 of the New York State Civil Service Law and NYCRR Rule 73.4 for the principal purpose of determining eligibility of individuals to participate in these programs and to maintain up-to-date records for covered employees. This information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e), and (f). Failure to provide this information may result in the disapproval of an individual to participate in these programs or a delay in the payment of benefits. This information will be maintained by the Director, Employee Benefits Division, New York State Department of Civil Service, The State Campus, Albany, NY 12239. For further information relating only to the Personal Privacy Protection Law, call (518) 457-9375.



PRESENTATION OF MATERIALLY FALSE INFORMATION IN SUPPORT OF AN INSURANCE APPLICATION OR CLAIM IS PROHIBITED BY ARTICLE 176 OF THE PENAL LAW.


I ___________________________ hereby apply for a waiver of premium under the New York State Health Insurance Program.

 
If approved, this approval is contingent on the employee's continuing LWOP status throughout the waiver period. Should the employee return to the payroll, be terminated, retire or resign during the waiver period, this waiver of premium will terminate. 

Signature
__________________________________________

Date 								Telephone No. 
_____________________________		________________________


PART B  (To be completed by Agency.) 

PLEASE PRINT OR TYPE 

Applicant's Title 
_______________________________________________________

Applicant's Birth Date __________			Date Leave Without Pay Began __________
Enrollment Option _______________
Agency Code No. _________________			Tel. No. ______________________________
Agency Name _____________________
 
Signature of Health Benefits Administrator 		Date 
__________________________________________		_______________________________________

PART C PLEASE PRINT OR TYPE (To be completed by attending physician.) 

Physician's Name ____________________ 		Physician's Address ___________________________

Telephone Number (including area code) ________________________

1. Complete Medical Diagnosis: (attach additional sheets if necessary) 

2. When did the disability first prevent the employee from performing his or her regular duties? (Month/Day/Year) _________

3. Is the employee currently disabled? 		Yes/No 

4. On what date did you FIRST treat the employee for this disability? (Month/Day/Year) _________

5. When did you LAST examine the employee? (Month/Day/Year) _________

6. When will the employee be able to resume his or her regular duties? (Month/Day/Year) _________

7. COMMENTS: 

PLEASE NOTE: 

Unless all questions are answered completely, a determination cannot be made. 


Date 					Personal Signature of Physician M.D. 
____________________	___________________________________________

MAIL FORM DIRECTLY TO:

New York State Department of Civil Service
Employee Benefits Division
The State Campus
Albany, New York 12239. 

PART D (To be completed by New York State Department of Civil Service, Employee Benefits Division.) 

The waiver of premium application is    
Waiver effective      
Approved to      
Disapproved 


Date 					Signature 
_________________		__________________________________