To submit the completed NYS Health Insurance Transaction Form, you can email it to your designated Agency Health Benefits Administrator. Alternatively, fax your form to the appropriate number as indicated in your agency's instructions. Physical submissions can be sent to the NYS Department of Civil Service, Employee Benefits Division, Albany, NY 12239. Always ensure you keep a copy of your submission for your records. Make sure to follow up with your administrator to confirm that your form has been received.

There aren't specific important dates for this form in 2024 and 2025, but keep in mind that timely submission is critical for health coverage. Always check for any deadlines related to enrollment periods. It is important to stay updated on any changes in insurance policy dates.

The purpose of this form is to facilitate health insurance transactions for NYS retirees and their dependents. By providing detailed enrollment options and changes, it ensures that all enrollees can maintain appropriate health coverage. This form also serves as a crucial document for notifying the NYS Department of Civil Service about significant life events impacting health insurance eligibility.

• 1. Last Name: Required field for the enrollee's surname.
• 2. First Name: Required field for the enrollee's given name.
• 3. Social Security Number: Unique identifier needed for enrollee identification.
• 4. Mailing Address: Current address for correspondence related to health insurance.
• 5. Date of Birth: Enrollee's birthdate for age verification.
• 6. Telephone Number: Contact numbers for the enrollee.
• 7. Marital Status: Indicate the current marital status of the enrollee.
• 8. Dependent Information: Details of dependents requiring coverage.
• 9. Preferred Plan: Selection between available NYSHIP options.
• 10. Signature: Signature of the enrollee indicating consent.

Failure to submit this form could result in a lapse in health insurance coverage for you and any dependents listed. It is crucial to ensure all sections are properly completed and submitted on time. Without this form, you may not be able to enroll or make necessary changes to your health insurance benefits.

• Loss of Coverage: Without form submission, you risk losing current coverage.
• Delayed Benefits: Submission delays may result in postponed healthcare benefits.
• Inaccurate Information: Mistakes could lead to complications in receiving benefits.

• 1. Enroll in NYS Health Insurance: To initiate coverage under NYSHIP.
• 2. Update Personal Information: When changes occur in address, marital status, or dependents.
• 3. Request Coverage Changes: If you need to switch plans or modify enrollment.