PART A � EMPLOYEE'S STATEMENT 

Employee's Name  			Health Insurance Identification Number
  
Employee's Address 			Employing Agency  No. 

Street  		City  		State  			ZIP Code  


I have read the eligibility requirements on the reverse side of this form.I attest that I am the Head of Household and Sole Wage Earner as defined.  I understand that if I make a fraudulent statement, I may lose my eligibility for Health Insurance coverage through the NYS Health Insurance Program. Also should it be determined I am not eligible, I understand that I will have to repay any money paid to me and/or to providers on my behalf as a result of this benefit. 


Signature of Employee 						Date 


PERSONAL PRIVACY PROTECTION LAW NOTIFICATION 

This information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e) and (f). This information will be maintained by the Director, Employee Benefits Division, Department of Civil Service, the W. Averell Harriman State Office Building Campus, Albany, New York 12239. For further information relating only to the Personal Privacy Protection Law, call (518) 457-9375. For further information about the reduced maximumout-of-pocket coinsurance, contact your agency Health Benefits Administrator. 


Eligibility RequirementsReduced Maximum Out-of-Pocket Coinsurance Expense

Head of Household:

	You may be single, married and/or separated from your spouse or divorced. 
	You must have at least one individual residing in your home who meets the dependent eligibility	requirements outlined 	in your NYSHIP General Information Book. 

Sole Wage Earner:

	You must provide for the family unit all the income derived from wages, except for wage income earned by a dependent 	from casual employment. 

Salary Requirement: 

	For the claim year starting January 1, 1998, you must have been earning $20,962 or less in base annual salary on 	October 1, 1997. To be eligible for the claim year starting January 1, 1999, you must have been earning $21,696 or 	less in base annual salary on October 1, 1998. 

Instructions for Application: 

	1.Employee completes Part A. Attach to your application a paycheckstub for the period that includes the eligibility 	  date shown above.

	2.Submit application to your Health Benefits Administrator. 

	3.Employee's Agency Health Benefits Administrator completes Part B. 

	4.Health Benefits Administrator sends application with proof of salary eligibility attached to: 

		NYS Department of Civil Service Employee Benefits Division
		Contract Management
		The State Campus 
		Albany, New York 12239

	5.Employee mails claims directly to: 
	
		United HealthCare Service Corp.
		Administrator for MetLife
		P.O. Box 1600
		Kingston, New York 12401-1600