Get Ny Ps-404 2020-2025

The NY PS-404, Health Insurance Transaction Form, is essential for New York State and Participating Employers' employees to manage their health insurance coverage effectively. This guide provides straightforward, step-by-step instructions for completing this form online, ensuring users can navigate it with confidence.

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

1. Press the ‘Get Form’ button to access the NY PS-404 document and open it in the chosen editor.
2. Complete the employee information section (Boxes 1-11) by filling in your last name, first name, middle initial, social security number, sex, date of birth, and personal contact details, including primary and work telephone numbers, and email address.
3. Indicate your marital status, selecting from single, married, widowed, divorced, or separated. If applicable, include the date of this status change.
4. Navigate to the Elect or Decline Coverage section (Boxes 12A-B) to choose your pre-tax or after-tax status for premium deductions. Select between Individual Enrollment, Family Enrollment, opt-out program, or declining coverage.
5. If electing coverage, specify the type (Medical, Dental, Vision) by checking the appropriate boxes under the selected coverage option. Review eligibility requirements if opting for the NYSHIP HMO.
6. For changes or cancellations of existing coverage, complete Box 13. Indicate whether you are changing coverage, including the reason for the change, and provide the date of the event prompting the change.
7. Fill out Box 14 if you are adding, deleting, or changing dependent information. Ensure the dependent’s information, including social security number and relationship, is accurately noted.
8. In Box 15, submit any annual option transfer requests if relevant. Make sure to include changes to NYSHIP options or status changes during the appropriate periods.
9. Finally, review all entered information for accuracy, then sign and date the form as required. Once completed, save your changes, download your form if needed, and prepare for submission.

Take control of your health insurance coverage by completing the NY PS-404 online today.