The State Health Insurance Program has a Coordination of Benefits Provision that applies when you or any dependent receive benefits under more than one health insurance program. Coordinating benefits helps to contain the cost of health care and can save you some out-of-pocket expenses when balances remain after one carrier has made its claim payment. 
Please return the completed form to your agency Health Benefits Administrator. 

SECTION I. 		OTHER COVERAGE B: 		OTHER COVERAGE A: 

SECTION II. 
		

EMPLOYEE INFORMATION:

ALWAYS COMPLETE SECTION I.

EMPLOYEE INFORMATION  

NAME: 			LAST 			FIRST 			M.I. 

SOCIAL SECURITY NUMBER 				DATE OF BIRTH 

STREET ADDRESS 		MARITAL STATUS 		SEX  

CITY 		STATE 		ZIP CODE 		EMPLOYING AGENCY CODE 




PERSONAL PRIVACY PROTECTION LAW NOTIFICATION: 

This information is being requested pursuant to �163 of the New York State Civil Service Law for the purpose of determining the availability of benefit coordination and to maintain up-to-date records for covered employees and their dependents. This information will be used in accordance with �96(1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e) and (f). Failure to provide this information may result in a delay in the payment of benefits. While this information will be maintained by the Insurance Carrier, the Director of the Employee Benefits Division, Department of Civil Service, The State Campus, Albany, NY 12239, is responsible for these records and information contained therein may not be released without the Director's authorization. 


I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT 

SIGNATURE: 						DATE: 


FOR FURTHER INFORMATION ONTHE COORDINATION OF BENEFITS FORM, CONTACT YOUR PERSONNEL OFFICE. 

Agency Information:

Attach this form to a COB Transmittal Notice (PS-601) and mail directly to Central Enrollment File atEmpire Blue Cross/Blue Shield.