Publications & Forms

Employees of Participating Employers (PE)

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PE Active 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 for New York State

PS 157 (2/2026) NYS Dependent Survivor Transaction Form (initial survivor enrollment only)

PS 404 (6/2025) NYSHIP Health Insurance Transaction Form for NYS & PE Employees

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

PS 405 (3/2026) NYSHIP Sick Leave Credit Option Election Form

PS 406.2 (3/2026) NYSHIP Health Insurance Deferral Election Form

PS 410 (3/2026) NYSHIP Sick Leave Credit Preservation Form

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 431 (3/2026) Health Insurance and Dental/Vision Insurance for Employees on Leave Without Pay

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 850 (2/2026) Change of Address Form (for NY Active Enrollees and for NY and PE Retirees)

YAO (4/2026) Request for Coverage Under the Young Adult Option

Management/Confidential (M/C) Life Insurance

PS-932 (4/2026) M/C Life Insurance Transition to Retirement Notice

PS 934 (4/2026) M/C Life Insurance Transaction Form

PS 934.1 (4/2026) M/C Life Insurance Beneficiary Designation Form

Statement of Review for Continuance of Life Insurance Protection During Total Disability (9-15)

SOH-ST100M-NY (08/2022) Statement of Health (Metropolitan)

PE Active Current Publications

Employee Information Day/Health Fair Planning Information Form

Guidelines for NYSHIP Participation at PA/PE Employer Health Fairs

HMO Contact Information

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

Print or View Form for PE and PA Agencies

HIPAA Documents