Get Ps-452 Application For Waiver Of Premium - Cs Ny

This guide provides step-by-step instructions on how to complete the PS-452 Application For Waiver Of Premium online. By following these instructions, users can ensure that they submit their application accurately and efficiently.

Follow the steps to complete your application online:

1. Press the ‘Get Form’ button to access the application form for waiver of premium and open it in your chosen editor.
2. Fill out Part A, which is to be completed by the enrollee. Provide your full name, health insurance ID number, date of birth, home address, city, state, zip code, and a telephone number.
3. Sign and date the application in the designated area to confirm your request for the waiver under the New York State Health Insurance Program.
4. Leave Part C blank as this section is to be completed by United Health Care.
5. Part B must be completed by your employing agency. Ensure they fill in the effective date of leave without pay status, health insurance coverage type, agency details, authorized signature, and date.
6. Request your attending physician to complete Part D once Parts A and B are finalized. They will need to provide their name, address, phone number, and information concerning the employee’s disability.
7. After completing all the parts of the form, ensure that all sections are reviewed for accuracy. Then, mail the completed application to United HealthCare at the specified address.
8. Finally, save any changes made to the form and if required, download, print, or share the document as needed.

Complete your PS-452 Application For Waiver Of Premium online today!