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Health Insurance Forms
New York State Health Insurance Program (NYSHIP)
Health Insurance Enrollment:
Pre-Tax Contribution Program (PTCP) Fact Sheet
PS404 NYS Health Insurance Transaction Form
PS-404(G) - SEHP (GSEU) Health Insurance Transaction Form
NYS Opt-Out Attestation Form (PS-409)
Statement of Disability for Dependents (PS-451)
Statement of Dependence for "Other" Children (PS-457)
Dependent Proofs Required for Enrollment
Coverage Request for Young Adult Option (YAO)
Domestic Partner Forms:
PS-425 Application & Instructions for Enrolling Domestic Partner
Termination of Domestic Partnership (PS-425.4)
Retiree Health Forms:
PS-405 Sick Leave Credit Option Election
PS-406.2 - Deferred Health Insurance for Retirees
PS-410 Sick Leave Credit Preservation
Disability Forms:
PS-451 Statement of Disability
PS-452 Application for Waiver of Premium
HIPAA Protected Health Information Release:
EBD-543 HIPAA Release
Insurance
Health Insurance Forms
Dental Insurance
Long-Term Disability Insurance
M/C Income Protection Plan
M/C Life Insurance
Vision Insurance
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