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
JOHN F. BARR
EXECUTIVE DEPUTY COMMISSIONER
NY04-24
PE04-23
PA04-19
TO: NYSHIP Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: Revised Forms:Instructions and Application for Statement of Disability Dependent 19 Years of Age or Older - PS 451I (8/04/L) & PS 451 (8/04L)Instructions and Application for Waiver of Premium - PS 452I (3/04) & PS452 (3/04L)
DATE: October 4, 2004
Enclosed are new versions of the above noted forms. Please discard any old versions of these forms you have in stock and begin to use these forms immediately. The PS 451 and PS 451I were revised in order to comply with HIPAA privacy regulations regarding protected health information and to update carrier contact information. The PS 452 and 452I were revised to update carrier contact information.
If you have any questions regarding the procedures or completion of the forms contact your processor.
These forms are also available on PA-MARKET at http://www.cs.state.ny.us/ebdonline.