Get Ps451 Form

The Ps451 Form is an essential document for individuals seeking to continue health insurance coverage for a disabled dependent aged 19 or older under the New York State Health Insurance Program. Filling out this form correctly is crucial to ensure that your dependent receives the necessary support and benefits.

Follow the steps to complete the Ps451 Form accurately

1. Click the ‘Get Form’ button to access the Ps451 Form and open it in your editing interface.
2. Begin by completing Part A of the form. Provide the enrollee's name, health insurance ID number, home address, phone number, city, state, and zip code. This section is important for identifying the individual requesting continued coverage.
3. In Part A, clearly indicate your request for NYSHIP coverage continuation for the dependent. If the dependent is not your biological child, ensure you have submitted a PS-457 Statement of Dependence to your Agency Health Benefits Administrator.
4. Fill out the dependent information section. Enter the dependent's name, relationship to the enrollee, social security number, and date of birth. Confirm their current employment status and provide an explanation if they are employed.
5. Indicate whether the dependent is enrolled in Medicare A and B, and their marital status. Include the percentage of support you provide for the dependent. If they are enrolled in Medicare, attach a copy of their Medicare card.
6. Check the box confirming that the dependent is permanently residing with you and specify the start date of residence. This information is crucial for coverage eligibility.
7. Ensure the enrollee's signature is present at the bottom of Part A along with the date. This validation is necessary to proceed with the form.
8. Next, part B must be completed by the employing agency. They will indicate the effective date of insurance for the dependent and verify that the dependent meets eligibility requirements.
9. Leave Part C blank; this will be completed later if necessary by the health maintenance organization or UnitedHealthcare.
10. Part D is to be filled out by the attending physician. They will need to provide a description of the dependent's disability, including dates and all necessary information.
11. Once all relevant sections are completed, the enrollee or attending physician must mail the completed form to the appropriate carrier, depending on whether the enrollee is with the Empire Plan or an HMO.
12. Finally, consider saving your changes, downloading a copy, printing the completed form, or sharing it as needed to maintain a record of the submission.

Complete the Ps451 Form online today to ensure your dependent continues to receive their health insurance benefits.