Form Ps-404 - Nys Health Insurance Transaction Form Page 2

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NYS Department of Civil Service
Health Insurance Transaction Form
Albany, NY 12239
Page 2 - PS-404 (9/15)
13.
ENTER ANNUAL OPTION TRANSFER REQUEST(S) BELOW
Change to:
Empire Plan
HMO Code
HMO Name
Change NYSHIP Option
Individual Opt-out
Family Opt-out
Elect Opt-out (if eligible)
If choosing Opt-out, you must also complete the PS-409 Opt-out Attestation Form.
Submit during the Pre-Tax Contribution Selection Period
Change to:
Pre-Tax
Post-Tax
Change Pre-Tax Status
(November 1-30)
14.
LEAVE WITHOUT PAY AND RETIREMENT STATUS
I wish to continue coverage while I am on authorized leave.
Medical
Dental
Vision
LEAVE WITHOUT
I understand that I will be billed and must pay for this coverage.
PAY
I do not wish to continue coverage while I am on authorized
Medical
Dental
Vision
leave. I wish to resume my coverage upon return to the payroll.
I understand the requirements for continuing medical insurance coverage as a retiree and wish to
continue my coverage.
I understand the requirements for continuing medical insurance coverage as a retiree and wish to
RETIREMENT
defer my coverage. (A completed PS-406.2 must be attached.)
I understand that I will receive an application for COBRA continuation of Dental and/or Vision
coverage automatically.
Personal Privacy Protection Law Notification
The information you provide on this application is requested in accordance with Section 163 of the New York State Civil Service Law for
the principal purpose of enabling the Department of Civil Service to process your request concerning health insurance coverage. This
information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e) and
(f). Failure to provide the information requested may interfere with our ability to comply with your request. This information will be
maintained by the Director of the Employee Benefits Division, NYS Department of Civil Service, Albany, NY 12239. For information
concerning the Personal Protection Law, call (518) 457-9375. For information related to the Health Insurance Program, contact your
Health Benefits Administrator. If, after calling your Health Benefits Administrator, you need more information, please call (518) 457-
5754 or 1-800-833-4344 between the hours of 9:00 a.m. and 4:00 p.m.
AUTHORIZATION
I have read the Pre-Tax Contribution Program materials and the Opt-out Attestation Form (if applicable), and have made my selection on
Page 1 of this document. I understand that if my coverage is declined or canceled, I may subject myself and/or my dependents to waiting
periods if I decide to enroll at a later date and may forfeit the right to such coverage after leaving State service (vest, retirement, etc.). I
am aware of how to obtain a current Summary of Benefits and Coverage for the NYSHIP option I have selected. I understand that my
failure to provide required proof(s) within 30 days may delay the availability of benefits for me or any dependent for whom I fail to provide
such proof. Any person who makes a material misstatement of fact or conceals any pertinent information shall be guilty of a crime,
conviction of which may lead to substantial monetary penalties and/or imprisonment, as well as an order for reimbursement of claims. I
certify that the information I have supplied is true and correct. I hereby authorize deduction from my salary or retirement
allowance of the amount required, if any, for the coverage indicated above.
Employee Signature
Date:
(Required):
AGENCY/EBD USE ONLY
Percentage
Neg.
Retirement
st
Action/Reason
Date of Event
Hire Date
Date of 1
Eligibility
Agency Code
Working
Unit
System
Sick Leave Information
Date Entered on
Retirement Tier
Registration #
Effective Date
NYBEAS
# Hours
Hourly Rate of Pay
HBA Signature
Date:
(Required):

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