The enrollee completes page 1, the physician page 3 and the plan administrator page 2.
Marital status: To continue coverage for a disabled dependent child, the dependent must be unmarried.
Medical coverage: The disability must have begun prior to the end of the month of the child's 26th birthday.
Disability certified through: Maximum 7 years per certification.
Physician portion: Unless all questions are answered completely, a determination cannot be made.
| Question | Answer |
|---|---|
| Form Name | PS-451 |
| Form Length | 4 pages |
| Fillable? | Yes |
| Fillable fields | 54 |
| Avg. time to fill out | 9 min |
| Edition | 3/2026 |
| Issuing agency | Department of Civil Service |
| Where to send | Empire Plan or NYS Dental & Vision only enrollees mail to UnitedHealthcare, PO Box 1600, Kingston, New York 12402-1600; HMO enrollees mail the form directly to their HMO |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | PS-451, PS451, Form PS-451, NYSHIP Statement of Disability for Dependents, NYSHIP disabled dependent form |
| Official source | PS-451 (Rev 3/2026), Department of Civil Service |
Form Ps 451 isn’t the one you’re looking for?