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ASE PRINT AND CHECK THE APPROPRIATE CHOICES. 1. 4. Street Address 5. Date of Birth (All employees must complete) EMPLOYEE INFORMATION First Name MI 2. Social Security Number 3. Sex Male Female Last Four Digits: City State Zip Last Name 6. Telephone Numbers Home ( ) 8. Marital Status Single Married Widowed 9. Covered under Medicare? Divorced Separated Self Yes 10. A. No Work location and address ) Marital Status Date Spouse/Domestic Partner Yes No Child Yes No ENTER REQU.

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The Affordable Care Act (ACA) requires almost every individual and each of his or her dependents to have health insurance coverage. If they do not have health insurance, they must claim an exemption or pay a tax penalty on his or her federal income taxes the following year.

You can reach NY State of Health by calling us toll free at 1-855-355-5777 (TTY: 1-800-662-1220). If you have questions about health plans, financial assistance, or anything else about NY State of Health please contact our Customer Service Representatives at 1-855-355-5777.

1-800-MEDICARE (1-800-633-4227) For specific billing questions and questions about your claims, medical records, or expenses, log into your secure Medicare account, or call us at 1-800-MEDICARE.

Please call the NY State of Health Customer Service Center at 1-855-355-5777 if you need additional information or if you would like to receive instructions regarding mailing or faxing your documentation. How do I use my insurance?

State Health Benefits Plans provide health insurance through the New York State Health Insurance Program (NYSHIP).

1-800-663-6114 - Complaints/Inquiries (Monday-Friday 9:00 a.m - 5:00 p.m.)

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232