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Will expire after my dependent s eligibility for coverage has been determined and implemented by the Department of Civil Service in its administration of the NYSHIP health plans. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and no longer be protected by HIPAA. Enrollee s Signature PART B Date (To Be Completed By Employing Agency) Effective Date Of Insurance For Dependent Above. Enrollee s Health Insurance Coverage: Individual Fa.

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