INSTRUCTIONS FOR THE PS-404
NYS HEALTH INSURANCE TRANSACTION FORM
PS-404 I (6/01L)
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All enrollees must complete |
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Complete appropriate
sections. The employee is entitled to make separate choices regarding their
medical, dental and vision coverage. They may decline any of the three, all of
the three, or none of the three different coverage options. Also, they many
enroll in family coverage in one benefit and individual coverage in another. Reminder: Enrollees
with a Benefit Fund (CSEA, UUP and DC-37) receive their dental and vision
benefits through that Fund. Do not enter dental and vision information on
NYBEAS for these enrollees. |
New Enrollees (also
complete 10.G for family coverage)
Note: for new enrollments in
a Health Maintenance Organization (HMO), complete an HMO form in addition to
this form.
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10.A |
Request Enrollment – Individual |
Check box to enroll in individual coverage. Check Medical,
Dental and/or Vision boxes for coverage being enrolled. |
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10.B |
Request Enrollment – Family |
Check box to enroll in family coverage. Check Medical, Dental
and/or Vision boxes for coverage being enrolled. |
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10.C |
Elect Pre-Tax Status? |
New Enrollees choose to enroll in or decline the Pre-Tax Contribution
Program for medical coverage. |
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10.D |
Decline Coverage |
Check box to decline coverage. Check Medical, Dental and/or
Vision boxes for coverage being declined. |
Cancellation or Change
in Coverage
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10.E |
Voluntarily Cancel Coverage |
The enrollee is entitled to make separate decisions regarding
their medical, dental and vision coverage. Enrollees may cancel or change
their dental and/or vision coverage(s) at any time during the year. Pre-tax
medical enrollees may only cancel coverage during the Pre-Tax Open Enrollment
Period, or with a qualifying event (enter the qualifying event). If you are
going on Leave Without Pay, also complete |
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10.F |
Change Coverage |
Check this box to change from Individual to Family, or from
Family to Individual coverage. Pre-tax medical enrollees may only change
their coverage from Family to Individual during the Pre-Tax Open Enrollment
Period, or with a qualifying event (check the qualifying event and enter the
Date of Event). Check Medical, Dental, and/or Vision boxes for coverage being
changed. |
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10.G |
Add/Change/Delete Dependents |
Check the box to add or delete dependents or to change
dependent information. Check Medical, Dental, and/or Vision boxes that apply.
Complete all dependent information including date of birth. Additional
documentation may be required to add the dependent. |
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10.H |
Change Medical Benefit Plan |
Complete during annual Option Transfer Period or with a
qualifying event (for example, change of address outside of HMO area.) |
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10.I |
Change Pre-Tax Status |
Existing enrollees can only change pre-tax status during the
annual Pre-Tax Open Enrollment Period in November. |
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AUTHORIZATION |
Employees must SIGN and DATE this form. |
EXAMPLES OF DOCUMENTATION REQUIRED TO PROCESS YOUR TRANSACTION
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Employees |
Spouse/Domestic
Partner |
Children |
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Copy of Birth Certificate |
Copy of Birth Certificate |
Copy of Birth Certificate |
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Copy of Social Security Card |
Copy of Social Security Card |
Copy of Social Security Card |
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Copy of Marriage Certificate or Complete PS-425 series
Domestic Partner, if Applicable |
Completed PS-451 - Statement of Disability and Required
Documentation, if Applicable |
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For Changes of Coverage, copy of Marriage Certificate, Divorce
Order, Death Certificate, PS-425.4 (Domestic Partner), as appropriate |
Completed PS-457 - Statement of Dependence and Required
Documentation, if Applicable |