Get Ny Ps-452 2020-2026

The NY PS-452 is an essential application for those seeking a waiver of the Empire Plan premium due to total disability. This guide will provide a clear, step-by-step process for completing the form online, ensuring you understand each section and its requirements.

Follow the steps to complete the NY PS-452 application online.

1. Press the ‘Get Form’ button to obtain the NY PS-452 and open it in your preferred online platform.
2. In the Enrollee portion, fill out the fields requesting your last name, first name, middle initial, date of birth, Empire Plan ID number, and home address including city, state, and zip code.
3. Indicate whether you are applying for your first waiver of Empire Plan premium related to this sickness or injury, or if it is an additional waiver.
4. Read and understand the Personal Privacy Protection Law Notification. This section clarifies how your information will be used in processing your request.
5. Complete the HIPAA Privacy Authorization section by signing and dating the form to authorize your physician to release relevant health information.
6. Once you have completed your portion of the form, provide pages 2 and 3 to your treating physician for their input.
7. After the physician completes their part, ensure they send all pages to UnitedHealthcare at the designated address.
8. The Plan Administrator from UnitedHealthcare will then fill out their part and send the necessary pages to the Employee Benefits Division.
9. Make sure to keep a copy of the completed application for your records before submitting.
10. Review the entire application to ensure all information is accurate and complete before final submission.

Start your application process online now to secure your waiver of the Empire Plan premium.