Form Ps 404 Pe – Fill Out and Use This PDF

The PS 404 PE form, issued by the State of New York Department of Civil Service, serves as a comprehensive tool for employees of participating employers to manage transactions related to their New York State health insurance coverage. This includes requests for enrollment, changes in coverage, and adjustments to pre-tax status, among other options. For those looking to make any updates to their health insurance benefits through the State of New York, properly completing this form is a crucial step. Ensure your health insurance needs are met by clicking the button below to fill out the PS 404 PE form.

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Form Ps 404 Pe PDF Details

In navigating the complexities of health insurance within the State of New York, the PS-404 PE form emerges as a pivotal document for employees seeking to adjust their health insurance benefits through participating employers. Developed by the New York Department of Civil Service, this form facilitates various transactions related to the New York State Health Insurance Program (NYSHIP). Employees are required to fill out comprehensive personal information, including their name, social security number, marital status, and whether they or any dependents are covered under Medicare. Additionally, the form allows for requests such as enrolling in new coverage, changing existing coverage, or canceling coverage, incorporating choices between the Empire Plan or an HMO, and deciding on pre-tax status for premium deductions. Noteworthy is the provision for dependent information, facilitating additions, deletions, or changes, catering to life events that affect dependents' eligibility. Furthermore, the form addresses scenarios for employees on leave without pay and those approaching retirement, highlighting options for continuing, deferring, or reinstating coverage. Instructions also cover the acquisition of duplicate or replacement Empire Plan cards, emphasizing the form's role in managing the intricate relationship between employment, personal life events, and health insurance coverage. The inclusion of a section on previous coverage underscores the importance of maintaining continuous health insurance, and the personal privacy protection notification assures applicants of the confidentiality and intended use of the provided information, underscoring the form's comprehensive nature in addressing employees' health insurance needs and transitions within the New York state context.

Question	Answer
Form Name	Form Ps 404 Pe
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	PS-404, Enrollee, misstatement, NYBEAS

Form Preview Example

State of New York

Department of Civil Service

Alfred E. Smith State Office Bldg.

Albany, NY 12239

EMPLOYEE BENEFITS DIVISION

NYS HEALTH INSURANCE TRANSACTION FORM

For Participating Employers PS-404 PE (1/07)

INSTRUCTIONS: READ AND COMPLETE BOTH SIDES/PAGES. PLEASE PRINT AND CHECK THE APPROPRIATE CHOICES.

EMPLOYEE INFORMATION

(All employees must complete)

Last Name

First Name

2. Social Security Number

3. Sex

Male

Female

Street Address

City

State

Zip

Date of Birth

6. Telephone Numbers

7. Work location and address

Home (

)

Work (

)

Marital Status

Married

Divorced

Marital Status Date

Single

Widowed

Separated

Covered under Medicare? Self

Yes

Spouse/Domestic Partner/Dependent?

Yes

10.

ENTER REQUEST(S) BELOW

Request Enrollment-

(Select Empire Plan or HMO)

Individual

Empire Plan

HMO* Code

Name

Request Enrollment-

(Select Empire Plan or HMO)

Family (Complete G)

Empire Plan

HMO* Code

Name

Elect Pre-Tax Status for

Yes

Note: pretax deductions may not be offered by all

Premium deduction?

agencies. Verify eligibility with your agency.

Decline Coverage

For Agency Use:

(Process WAV/BEN transaction)

Voluntarily Cancel Coverage

Change Coverage

Date of Event

Change to FAMILY (Complete G)

Change to INDIVIDUAL

I voluntarily cancel coverage for my dependents

Marriage

I voluntarily cancel coverage for my domestic partner

Domestic Partner

Only dependent died

First dependent child acquired

Only dependent married

Dependent returned to full-time student status

Only dependent graduated

Request coverage for dependents not previously covered

Divorce

Newborn

Only dependent disqualified by age

Previous coverage terminated (Complete Section 11)

Termination of domestic partnership (Attach Completed PS-428.4)

Other

DEPENDENT INFORMATION

(use additional sheets if necessary)

Check One: A (Add), D (Delete) or C (Change)

Date of Event

Last Name	First Name	MI	Relationship	Date of Birth	Sex	Address (if different)	Social Security
Last Name	First Name	MI	Relationship	Date of Birth	Sex	Address (if different)	Number
							Number
A
D
C
A
D
C
A
D
C
A
D
C
A
D
C

* A completed HMO form must be attached.

NYS Department of Civil Service

Health Insurance Transaction Form For Participating Employers

Albany, NY 12239

PS-404 PE (1/07) Page 2

10. Continued.

ENTER REQUEST(S) BELOW

H. Change Medical Benefit Plan

Change to:

Empire Plan

HMO * Code

HMO Name

* A completed HMO form must be attached.

11.

PREVIOUS COVERAGE INFORMATION

If you were previously covered under NYSHIP

Previous ID Number

Date Coverage

or another health insurance plan (attach proof,

Terminated

i.e. insurance bill or letter stating former

Enrollee’s Name Under

Last

First

Middle Initial

coverage), please complete this section.

Which Previously Covered

12.

LEAVE WITHOUT PAY AND RETIREMENT STATUS

I wish to continue coverage while I am on authorized leave.

LEAVE

I understand that I will be billed for this coverage.

WITHOUT PAY

I do not wish to continue coverage while I am on authorized leave.

I wish to resume my coverage upon return to the payroll.

I understand the requirements for continuing medical insurance coverage as a retiree and wish to continue my coverage.

RETIREMENT

I understand the requirements for continuing medical insurance coverage

as a retiree and wish to defer my coverage. (A completed PS-406.2 must be attached.)

13.	REQUEST FOR EMPIRE PLAN CARD ONLY

For Health Maintenance Organization (HMO) cards, contact your HMO.

	DUPLICATE CARD	FOR
	(Previously issued card remains valid.)	FOR
	(Previously issued card remains valid.)
	REPLACEMENT CARD
	(Previously issued card(s), lost or stolen, become invalid.)

ENROLLEE

ENROLLEE AND ALL DEPENDENTS INDIVIDUAL DEPENDENT

Name

Personal Privacy Protection Law Notification

This information you provide on this application is requested in accordance with Section 163 of the New York State Civil Service Law for the principal purpose of enabling the Department of Civil Service to process your request concerning health insurance coverage. This information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e) and (f). Failure to provide the information requested may interfere with our ability to comply with your request. This information will be maintained by the Director of the Employee Benefits Division, NYS Department of Civil Service, Albany, NY 12239. For information concerning the Personal Protection Law, call (518) 457-9375. For information related to the Health Insurance Program, contact your Agency Health Benefits Administrator. If, after calling your Agency Health Benefits Administrator, you need more information, please call (518) 457-5754 or 1-800-833-4344 between the hours of 9:00 a.m. and 3:00 p.m.

AUTHORIZATION

I have read the Pre-Tax Contribution Program memorandum and have made my selection on Page 1 of this document, if applicable. I understand that if I voluntarily decline or cancel my coverage, I may subject myself and/or my dependents to waiting periods if I decide to enroll at a later date, and I may be forfeiting the right to such coverage after leaving State service (vest, retirement, etc.). I certify that the information I have supplied is true and correct. I understand that my failure to provide required proof(s) within 28 days (30 days for newborns) may delay the availability of benefits for me or any dependent for whom I fail to provide such proof. Any person who makes a misstatement of fact or conceals any pertinent information, commits a crime which is subject to a $5,000 penalty and the stated value of the claim for each violation. I hereby authorize deduction from my salary or retirement allowance of the amount required, if any, for insurance indicated above. This authorization shall be in effect until I revoke it in writing.

Employee’s Signature (Required) ________________________________ Signature Date (Required) _________________

Action/Reason

Date of Event

Hire Date

AGENCY/EBD USE ONLY

Date of 1st	Percentage	Agency Code	Neg.	Ret. System
Eligibility	Working	Agency Code	Unit	Ret. System
Eligibility	Working		Unit

Retirement Tier

Registration #

Sick Leave Information

# Hours

Hourly Rate of Pay

Date Entered on

NYBEAS

Effective Date

HBA Signature:

Date:

How to Edit Form Ps 404 Pe Online for Free

By using the online PDF tool by FormsPal, it is possible to complete or change NYSHIP here. FormsPal expert team is ceaselessly working to develop the tool and ensure it is even easier for people with its cutting-edge functions. Bring your experience to a higher level with constantly growing and amazing options we provide! To get the process started, consider these simple steps:

Step 1: Access the PDF file inside our tool by hitting the "Get Form Button" in the top section of this page.

Step 2: With our advanced PDF editor, it is possible to do more than just complete blank fields. Try each of the functions and make your forms look perfect with customized text incorporated, or fine-tune the file's original input to perfection - all that accompanied by an ability to incorporate your own images and sign the PDF off.

It really is an easy task to complete the document adhering to this helpful guide! This is what you need to do:

1. You should fill out the NYSHIP properly, therefore take care when filling in the sections that contain all of these fields:

2. Given that the last segment is done, it's time to add the necessary particulars in Change Coverage, Date of Event Change to FAMILY, Change to INDIVIDUAL, Marriage Domestic Partner First, I voluntarily cancel coverage for, DEPENDENT INFORMATION use, Check One A Add D Delete or C, Date of Event, Last Name, First Name MI, Relationship Date of Birth, Sex, Address if different, Social Security, and Number so you're able to move forward further.

3. This third part is normally straightforward - fill out every one of the fields in A D C, A D C, A D C, and A completed HMO form must be in order to finish the current step.

4. Now complete this fourth part! In this case you have these Continued, ENTER REQUESTS BELOW, Change Medical Benefit Plan, Change to, Empire Plan, HMO Code HMO Name A completed, PREVIOUS COVERAGE INFORMATION, If you were previously covered, Previous ID Number Enrollees Name, Date Coverage Terminated, Last, First, Middle Initial, LEAVE WITHOUT PAY AND RETIREMENT, and LEAVE fields to fill out.

A lot of people frequently make mistakes while filling in Continued in this part. You should definitely read again what you enter right here.

5. As you reach the end of this document, you'll notice a couple more things to undertake. Mainly, I have read the PreTax, Employees Signature Required, ActionReason, Date of Event, Hire Date, AGENCYEBD USE ONLY, Date of st Eligibility, Percentage Working, Agency Code, Neg Unit, Ret System, Retirement Tier, Registration, Sick Leave Information, and Hours should all be filled out.

Step 3: When you've glanced through the information entered, simply click "Done" to finalize your form. Acquire your NYSHIP after you sign up for a free trial. Instantly use the document within your FormsPal account page, together with any edits and changes being conveniently synced! FormsPal is focused on the privacy of all our users; we make sure all information processed by our tool stays confidential.

Form Ps 404 Pe – Fill Out and Use This PDF

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