Get Ny Ps-404 2019

The NY PS-404 form is essential for employees participating in the New York State Health Insurance Program (NYSHIP). This guide offers clear, step-by-step instructions to help users complete the form accurately and effectively, ensuring that all necessary coverage choices are made.

Follow the steps to complete the NY PS-404 form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Provide your employee information in boxes 1 through 10. This includes your last name, first name, social security number, permanent address, date of birth, and contact details.
3. Indicate your marital status in box 9. Select the appropriate option and write the date of your marital status if it is applicable.
4. In box 11, choose whether to elect or decline coverage. Indicate your preference for medical, dental, and vision coverage, checking the appropriate boxes.
5. For box 12, select whether you want to change your existing coverage or cancel it, if necessary. Provide any required event dates to document your request.
6. Complete box 13 for dependent information, ensuring to include all necessary details such as names, dates of birth, and social security numbers of any dependents.
7. In box 14, enter any requests for annual option transfer. Make sure to complete this section during the designated periods.
8. Finally, review the authorization section. Ensure you sign and date the form, confirming that all information provided is accurate and truthful.
9. Once completed, users can save changes, download, print, or share the form as required.

Complete your NY PS-404 form online today to ensure you have the necessary health insurance coverage.