WebTermination of Domestic Partnership (Attach completed PS -425.4) Only dependent ineligible due to age I voluntarily cancel coverage for my dependents Only dependent died … WebCompleted PS-425 (Domestic Partner series) and required documentation Completed PS-45 7 ( Statement of Dependence) and required documentation, if applicable For changes of …
EMPLOYEE BENEFITS DIVISION PA HEALTH INSURANCE …
WebIndividual Opt-out Family Opt-out If choosing Opt-out, you must also complete the PS-409 Opt-out Attestation Form. 2. Elect Pre-Tax Status for Premium deduction Elect Post-Tax Status for Premium deduction Please read the Pre-Tax Contribution program materials. C. Decline NYSHIP Coverage Medical(10) Dental (11) Vision (14) 12. Web(1) individuals or organizations who are approved, licensed or otherwise regulated to practice or operate in the health care field under the laws of the Commonwealth, including, but not limited to, the following individuals or organizations: (i) a physician; (ii) a dentist; (iii) a podiatrist; (iv) a chiropractor; (v) an optometrist; jesus soa sangue
EMPLOYEE BENEFITS DIVISION NYS HEALTH INSURANCE …
WebJan 1, 2024 · § 425.4 Pennsylvania Statutes Title 63 P.S. Professions and Occupations (State Licensed) § 425.4. Confidentiality of review organization's records Current as of … WebPS-425.4 (3/17) I, certify that: Name of Enrollee (Please Print) I, and ... one year after the date this form is filed. I understand that my partner’s children named below, if any, that are covered under my NYSHIP enrollment will end (unless otherwise eligible) on the termination date of this domestic partnership. ... WebNYS HEALTH INSURANCE TRANSACTION FORM PS-404 (9/15) INSTRUCTIONS: READ AND COMPLETE BOTH SIDES/PAGES. PLEASE PRINT AND CHECK THE APPROPRIATE … jesus sobe ao céu