HMO Enrollment Form for NYS Employees

HOW TO COMPLETE THIS APPLICATION 1 PS404

1. Informatlon on this form is not offlclal without a completed NYS Health Insurance Transaction Form IPS404).
2. Use dark Ink. Press firmly so that all three copies are clear.
3. This form must be submitted, together with the PS404, to yovr Health Benefits Administrator.
4. All applicants MUST complete Sections 1 and 2 and in addition Sections 3.4 and 5 must be completed,
   if they apply to you.
5. Please sign form In the space indicated below.



SECTION 1 : Enrollee Information

Name		First	Last 	Middle

Address		Street	City	State	Zip	

Social Security Number		MAle/Female	Single/Widowed/Divorced

Phone		Work  (  )    -		Home   (   )    -


SECTION 2: Enrollment Information

Name of HMO				NYS HMO Code

Coverage	Individual/Family

Have you ever been a member of this HMO before?		Y/N

Subscribers Name		Self/ Spouse / Other (relationship)___________


SECTION 3: Spouse Information

Name		First	Last 	Middle

Address		Street	City	State	Zip	

Social Security Number		Birth Date __/__/____

Phone		Work  (  )    -		Home   (   )    -

Employed  	Y/N		If Yes, Employers Name and Address.

Health Insurance Company (If Different from your.)


SECTION 4: Dependent Information

Dependent Last Name		First		MI	Date of Birth	Son/Daughter


SECTION 5: Medicare Information

Are you enrolled in Medicare?		Part A (Hospital), Effective Date____ You___ Spouse___ Dependent (Name & Date)
					
					Part B (Medical),  Effective Date____ You___ Spouse___ Dependent (Name & Date)




Signature			Date