Follow the steps to fill out the Empire Station form online.

1. Press the ‘Get Form’ button to access the form and open it for completion.
2. Begin by providing your name in the designated fields. Enter your first name, middle initial, and last name as they appear on official documents.
3. Next, fill in your address information, including street address, apartment number (if applicable), city, state (New York), and zip code.
4. Input your date of birth in the requested format, as well as your home and work phone numbers. Include the area code for each phone number.
5. Provide your Social Security number in the appropriate fields, ensuring to separate each segment with dashes as indicated.
6. List your employer's name and address if applicable. Remember that under New York State law, certain medical information cannot be disclosed to your employer without your signed consent.
7. Next, complete the insurance company information section. Include the company's name, billing address, individual policy number, group policy number, and pharmacy benefits policy number.
8. Indicate the coverage start date and confirm your relationship to the policyholder by circling one of the provided options: self, spouse, dependent, or other.
9. Review the Assignment of Benefits statement and understand your responsibilities regarding payment remittance and notifying the Uninsured Care Programs of any changes to your coverage or address.
10. Finally, provide your signature and the date at the bottom of the form to certify that the information provided is accurate.
11. After completing all sections accurately, save your changes, download the form, print it, or share it as necessary to ensure submission.

Complete your form online today to ensure timely processing of your application.