Get See Reverse Side For Instructions For Completing - Department Of ... - Cs Ny

Completing the 'See Reverse Side For Instructions For Completing - Department Of ... - Cs Ny' form is essential for applicants seeking to reduce their maximum out-of-pocket coinsurance expenses under the New York State Health Insurance Program. This guide provides a professional, clear, and step-by-step process to assist users in successfully filling out the form online.

Follow the steps to complete your application effectively.

1. Press the ‘Get Form’ button to access the application form and open it in your online editor.
2. Begin by filling out the health insurance identification number at the top of the form. Ensure this number is accurate to avoid delays.
3. Enter the employee's full name in the designated field, ensuring it matches the official documents.
4. Provide the employee's address, including the street number, city, state, and ZIP code, in the appropriate fields.
5. Select the employing agency from the provided options or specify if not listed.
6. Indicate the claims year for which you are applying.
7. Read the eligibility requirements detailed on the reverse side of the form. Confirm your understanding by checking the box next to the statement about reading the requirements.
8. Attest to being the head of household and sole wage earner by checking the corresponding box. This confirms your eligibility status.
9. Be aware of the implications of providing false information regarding eligibility as mentioned in the form. Unsigned forms may delay processing.
10. Sign and date the form in the designated areas to validate your application.
11. Once Sections A and B are completed, gather the required documentation, including a copy of your most recent tax return and paycheck stub, as indicated in the instructions.
12. Submit the application to your Health Benefits Administrator for further processing.
13. After your Health Benefits Administrator fills out Section B, they will return the application along with necessary verifications.
14. Finally, mail your claims directly to the address provided for United HealthCare Service Corp. to complete the process.

Complete your application online to ensure a smooth filing process.