Publications & Forms

Employees and Retirees of Participating Agencies (PA)

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PA NYSHIP Publication Order Form

NYSHIP Insurance Forms and Support Material

Empire Plan Claims and Administrative Forms

Hospital Program - Anthem Blue Cross Claims Form

Medical/Surgical Program - Health Insurance Claim Form

Prescription Drug Program

CVS Caremark Mail Service Order Form

Prescription Drug Program Reimbursement Claim Form

Medicare Rx Reimbursement Claim Form

Mental Health and Substance Use Claim Form

Health Benefits Forms

PS 404S (1/2026) NYSHIP Health Insurance Transaction Form Additional Dependent Information Supplement

PS 425 Domestic Partner Series

PS 425 (1/2026) Instructions and Application for Enrolling Domestic Partners

PS 425.3 (1/2026) Dependent Tax Affidavit for Domestic Partners

PS 425.4 (1/2026) Termination of Domestic Partnership

PS 451 (3/2026) NYSHIP Statement of Disability for Dependents

PS 452 (3/2026) Application for Waiver of Empire Plan Premium

PS 457 (3/2026) Enrollment or Recertification of an "Other" Child as a NYSHIP Dependent Form

PS 503 (2/2026) NYSHIP Health Insurance Transaction Form for Participating Agencies (PAs)

PS 516 (4/2026) NYSHIP Health Insurance Transaction Transmittal Form for Participating Agencies

PA Active and Retiree Current Publications

Employee Information Day/Health Fair Planning Information Form

Guidelines for NYSHIP Participation at PA/PE Employer Health Fairs

Online PE and PA Agencies Employee Information Day/Health Fair Request Form

Print or View Form for PE and PA Agencies

HIPAA Documents