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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