Get NY DOH-4450 2013-2024

Failure to do so may result in court action and penalties. Employee Last Name First Name Address Is this individual currently enrolled in health insurance coverage through employment with you YES Complete Section A NO Complete Section B Does this individual have health insurance available to him/her now or in the future through employment with you SECTION A Employer Name Phone Insurance Carrier/Union Name Group Carrier Address Carrier Phone Name of person completing form Date Employee/Enrollee Coverage Dates Coverage Type Family/Couple/Individual Start Date Monthly Employee Premium Amount End Date What are the standard Deductibles Co-Insurance Co-payments Scope of Benefits Please check all that apply and attach a plan summary Ambulatory Surgery Outpatient Services Inpatient Hospital Services Emergency Services Physician Services DOH- 4450 11/13 Prescription Drug Durable Medical Equipment Transportation Emergency Dental Vision Care/ Eyeglasses Drug and Alcohol treatment Outpatient Mental Health Diagnostic Lab/ X-ray Maternity Care If employee is NOT enrolled in an employer-sponsored health care plan check the applicable box and attach the information requested. Health insurance is not provided to our employees Employee is not eligible for health care coverage because enroll on date // Employee is eligible for health insurance but has not enrolled Attach the plan s summary of benefits the employee spouse and dependents may be eligible for and the employee cost for such benefits. If your employee is determined to be eligible to receive premium assistance in paying his/her share of the premium cost would you accept direct payment from the Department of Social Services YES NO If yes Employer FEIN or Tax ID is needed. Please return this form within 15 days to the address below. If you cannot upload this form onto your account you may mail it to New York State of Health P. New York State Department of Health Division of Coverage and Enrollment EMPLOYER SPONSORED HEALTH INSURANCE REQUEST FOR INFORMATION Your Employee may be eligible for help in paying for health insurance premiums please provide information about the health insurance offered by your company and return it to the address at the bottom of this form. Pursuant to Social Services Law Section 143 all employers of any kind doing business within the State of New York are required to furnish to the social services official information about employees including information regarding health insurance coverage. Failure to do so may result in court action and penalties. Employee Last Name First Name Address Is this individual currently enrolled in health insurance coverage through employment with you YES Complete Section A NO Complete Section B Does this individual have health insurance available to him/her now or in the future through employment with you SECTION A Employer Name Phone Insurance Carrier/Union Name Group Carrier Address Carrier Phone Name of person completing form Date Employee/Enrollee Coverage Dates Coverage Type Family/Couple/Individual Start Date Monthly Employee Premium Amount End Date What are the standard Deductibles Co-Insurance Co-payments Scope of Benefits Please check all that apply and attach a plan summary Ambulatory Surgery Outpatient Services Inpatient Hospital Services Emergency Services Physician Services DOH- 4450 11/13 Prescription Drug Durable Medical Equipment Transportation Emergency Dental Vision Care/ Eyeglasses Drug and Alcohol treatment Outpatient Mental Health Diagnostic Lab/ X-ray Maternity Care If employee is NOT enrolled in an employer-sponsored health care plan check the applicable box and attach the information requested. Health insurance is not provided to our employees Employee is not eligible for health care coverage because enroll on date // Employee is eligible for health insurance but has not enrolled Attach the plan s summary of benefits the employee spouse and dependents may be eligible for and the employee cost for such benefits. .