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
NY03-21
PE03-14
PA03-09
TO: NYSHIP Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: Revised Forms PS – 452I Instructions for the Application for Waiver of Premium and PS – 452 Application for Waiver of Premium
DATE: May 2, 2003
Enclosed are new versions of the following forms:
PS – 452I Instructions for the Application for Waiver of Premium
PS – 452 Application for Waiver of Premium
Please discard any old versions of these forms you have in stock and begin to use these forms immediately. The form was revised in order to comply with HIPAA privacy regulations regarding protected health information. Please read through the instruction carefully as the procedure has changed. Any questions regarding the new procedure should be referred to the Leave unit for NY agencies and your processor for PA and PE agencies. The form is also available on PA-MARKET at http://www.cs.state.ny.us/ebdonline.