Get Instructions For Completing A Health Benefits ... - Nyc.gov

Completing the Health Benefits Application/Change Form is an important step for users seeking to manage their health benefits efficiently. This guide will provide you with a detailed, step-by-step process to ensure that you fill out the form correctly and submit it successfully.

Follow the steps to complete your Health Benefits application or change form.

1. Press the ‘Get Form’ button to obtain the application form and access it in your online editing tool.
2. Read through the instructions carefully. Begin by selecting the appropriate applicant category: either Employee, Retiree, or Line of Duty Survivor.
3. Indicate the reason for submission by checking one or more boxes in Section A. For new enrollment, or if you are adding/dropping coverage, be sure to specify the effective date where applicable.
4. Provide your personal information in Section D, including your last name, first name, M.I., Social Security number, address, date of birth, marital status, and contact numbers.
5. If applicable, fill out Section E for your spouse or domestic partner’s information, ensuring to include their Social Security number and Medicare details if they are eligible.
6. List all eligible dependent children in Section F, specifying whether you are adding or dropping coverage for each child.
7. In Section G, clearly write the full name of the health plan you wish to enroll in, and indicate if you want to include optional benefits.
8. If you are an employee wishing to participate in the Buy-Out Waiver Program, complete Section H and date your form.
9. Sign and date the required sections in Section I to authorize the changes or enrollment.
10. If you are a new retiree, ensure Section J is completed by your payroll or personnel office before submitting the form.
11. Once all sections are filled out, save your changes. You can download the completed form, print it, or share it as needed.

Start filling out your Health Benefits Application/Change Form online today to ensure your healthcare needs are met.