Get Ps 425

Filling out the Ps 425, the Domestic Partner Enrollment Application for the New York State Health Insurance Program, is a straightforward process. This guide will provide you with clear, step-by-step instructions to ensure your application is completed accurately and efficiently.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to access the Ps 425 document and open it for editing.
2. In the 'Employee Information' section, enter your last name, first name, middle initial, and social security number. Fill in your street address, city, state, zip code, date of birth, and telephone numbers.
3. Specify your gender by selecting either 'Male' or 'Female'. Indicate which type of coverage you wish to add for your Domestic Partner by checking the appropriate boxes for medical, dental, or vision.
4. In the 'Domestic Partner Information' section, provide your Domestic Partner's last name, first name, and social security number. Indicate whether your Domestic Partner is 65 or older and if they are covered under Medicare.
5. Affirm your eligibility for coverage under Section A by answering 'Yes' to all listed statements. Be prepared to provide the necessary documentation.
6. In Section B, ensure you submit the required proofs of joint responsibility for financial obligations and proof of cohabitation as specified in the application.
7. In Section C, determine if your Domestic Partner is a federally qualified dependent according to the Internal Revenue Code and check the corresponding box.
8. After filling out all sections, save your changes. You can download, print, or share the completed form as needed.

Complete your Ps 425 application online today to ensure your Domestic Partner is enrolled in the NYSHIP program.