Get Ny Enrollment/change Form Medical Spending Conversion (msc) 2021-2025

This guide provides a comprehensive overview of completing the NY Enrollment/Change Form Medical Spending Conversion (MSC) online. Follow these instructions to ensure that your form is accurately filled out and submitted to your agency's Human Resources department.

Follow the steps to complete the NY MSC Enrollment/Change Form online.

1. Press the ‘Get Form’ button to access the NY Enrollment/Change Form Medical Spending Conversion (MSC). This will open the form in the editing tool.
2. Begin by completing Section I, which requires personal information. Fill in your last name, first name, middle initial, social security number, home address (including apartment number, city, state, and ZIP code), home phone number, work phone number, mobile phone number, email address, and agency name.
3. Move to Section II, focusing on the MSC Health Benefits Buy-Out Waiver Program. Here, indicate your preference to participate in the Buy-Out Waiver Program and provide the name of your non-City group health plan provider. Select the relevant coverage type and ensure you attach proof of your coverage.
4. If you are making a mid-year enrollment due to a qualifying event, complete Section III. You will need to certify the event and provide supporting documentation, ensuring this is submitted within 30 days of the event.
5. In Section IV, sign and date the form to attest that you meet the qualifications for enrollment or withdrawal from the program.
6. If applicable, Section V must be completed by your agency’s Human Resources department. Ensure they review all provided information and documentation.
7. Once the form is completed, save your changes. You may download a copy for your records, print it for physical submission, or share it electronically with your agency's HR department.

Complete your NY Enrollment/Change Form Medical Spending Conversion (MSC) online today to ensure your benefits are accurately reflected.