The Empire Plan is a unique health insurance plan designed especially for public employees in New York State. Empire Plan benefits include inpatient and outpatient hospital coverage, medical/surgical coverage, Centers of Excellence for transplants, infertility and cancer, home care services, equipment and supplies, mental health and substance abuse coverage and prescription drug coverage.
GOVERNOR
DEPARTMENT OF CIVIL SERVICE
ALBANY, NEW YORK 12239
www.cs.ny.gov
COMMISSIONER
DANIEL E. WALL
EXECUTIVE
DEPUTY COMISSIONER
NY02-21
PE02-12
PA02-08
TO: New York State Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: Revised Form – PS-451 (Statement of Disability Dependent 19 Years of Age or Older) New Form – PS 451 I (Statement of Disability Dependent 19 Years of Age or Older Instructions)
DATE: May 29, 2002
The PS-451 – Statement of Disability Dependent 19 Years of Age or Older for Participating Employer Agencies and Participating Agencies has been changed from a three-part carbon form to a single copy two sided form. The instructions for completing the PS-451 appear in a separate new form – PS-451 I - Statement of Disability Dependent 19 Years of Age or Older Instructions. Please discard any old versions of the PS-451 that you have in stock and begin to use this form and the new PS-451 I immediately.
The PS-451 is designed to maintain the privacy of the enrollee. As the HBA, you should not have access to information completed in Parts D or E, which appear on the back of the PS-451. Please read the instructions carefully in PS-451 I for more information.
Keep the forms as a master copy to photocopy, or print the forms directly from our website.
If you have any questions, please contact your processor.
You will find the new forms under Publications & Forms, choose "Health Insurance Forms and Support Material", then choose "Health, Dental and Vision Forms for New York State & Participating Employers (PE) Agencies".