Get Employee Benefits Division Please Return The Completed Form ... - Cs Ny

This guide provides clear, step-by-step instructions on how to complete the Employee Benefits Division form for the New York State Health Insurance Program. The information contained within the form is essential for coordinating health benefits when an individual or their dependents are covered under multiple health insurance plans.

Follow the steps to complete your form accurately.

1. Press the 'Get Form' button to access the Employee Benefits Division form. This will open the document for you to begin filling it out.
2. In Section I, Employee Information, carefully fill in your details. Start with your last name and first name, followed by selecting your prefix and state (NY or PA). Ensure that your social security number is correctly entered, along with your full street address, city, state, and ZIP code.
3. Indicate your date of birth and marital status by selecting the appropriate option. You will also need to specify your gender by circling either 'Male' or 'Female'.
4. Provide your employing agency name and the corresponding agency code required in this section.
5. Next, enter the details for the dependent who has other coverage. Fill in their name, policy or identification number, date of birth, and the name and address of their other employer and insurance carrier.
6. Indicate the type of coverage your dependent has, choosing between 'Individual' or 'Family' as applicable.
7. In the Comments section, you can include any additional information that might be relevant, such as special circumstances regarding the coverage.
8. If you have more dependents with other coverage, check the appropriate box to indicate this in Section II.
9. Review the Personal Privacy Protection Law Notification section carefully to understand how your information will be used.
10. Finally, certify the accuracy of the information provided by signing and dating the form. Ensure you include the date of your signature.
11. Once all sections are completed, save your changes. If necessary, download, print, or share the completed form as required.

Complete your documents online now to ensure your health benefits are processed efficiently.