Get Nys Ps404 Instructions Form

Completing the Nys Ps404 Instructions Form online is an important step in managing your health insurance transactions with the State of New York. This guide provides clear instructions to ensure that you fill out the form correctly and efficiently.

Follow the steps to complete the Nys Ps404 Form online.

1. Click ‘Get Form’ button to obtain the Nys Ps404 Instructions Form and open it in your preferred editor.
2. Begin with the Employee Information section. Fill in your first name, middle initial, last name, and social security number. Provide your date of birth and contact details, including your street address, city, state, and zip code.
3. In the Telephone Numbers section, enter your home and work phone numbers. Indicate your marital status by choosing from options like 'Single,' 'Married,' 'Widowed,' 'Divorced,' or 'Separated.'
4. Complete the question regarding Medicare coverage. Select 'Yes' or 'No' based on your individual circumstances.
5. Fill out the Enrollment Request section where you can request enrollment for yourself or your family. Indicate whether you want medical, dental, or vision coverage and specify if you opt for the Empire Plan, HMO, or other options.
6. If applicable, elect the pre-tax or post-tax status for premium deductions, or indicate your intent to decline coverage.
7. Provide details in the Dependent Information section if enrolling dependents. Include last names, first names, relationships, dates of birth, and whether each dependent is being added, deleted, or changed.
8. If you have a previous coverage, fill out the Previous Coverage Information section, including your previous ID number and termination date.
9. Review and complete the Leave Without Pay and Retirement sections if they apply to your situation.
10. Finally, review all the information provided, sign and date the authorization at the bottom of the form confirming its accuracy.
11. Once completed, save all changes, and you can then download, print, or share the form as necessary.

Begin filling out your Nys Ps404 Instructions Form online today to effectively manage your health insurance transactions.