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Get Employee Benefit Ps 452 Form
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How to fill out the Employee Benefit Ps 452 Form online
Filling out the Employee Benefit Ps 452 Form online is a straightforward process that can help you apply for a waiver of health insurance premiums due to total disability. This guide provides you with clear, step-by-step instructions to ensure you complete the form accurately and efficiently.
Follow the steps to complete the Employee Benefit Ps 452 Form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Fill out Part A of the form as the employee. This section requires you to provide your name, home address, ID number, and other personal information. Ensure that all fields are completed accurately and legibly.
- Review the Personal Privacy Protection Law notification which informs you about how your information will be used and the importance of providing complete information.
- Sign and date the application in the designated section at the bottom of Part A. Make sure to include your telephone number.
- Proceed to Part B, which is to be completed by your agency. Provide the necessary details such as your title, birth date, and enrollment option. Ensure that the Health Benefits Administrator signs this section.
- In Part C, the attending physician will need to complete the medical details. Clearly communicate to them the need to fill out all required fields, including medical diagnosis, treatment dates, and the current disability status.
- Once all parts of the form are filled out, ensure that the physician mails Part C directly to the New York State Department of Civil Service, Employee Benefits Division, using the address provided.
- After completion, you may save your changes, download a copy, print the form for your records, or share it as needed.
Start filling out the Employee Benefit Ps 452 Form online today to ensure you stay on track with your application.
New York State employees typically have access to the Empire Plan through NYSHIP, which offers robust health insurance coverage. This plan includes various benefits such as medical, dental, and vision care. For specific details about your options, reviewing the Employee Benefit Ps 452 Form is highly recommended.
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