Download New York Ps 409 Template in PDF Open New York Ps 409 Editor Now

Download New York Ps 409 Template in PDF

The New York PS 409 form is an attestation form that allows eligible employees to opt out of the New York State Health Insurance Program (NYSHIP) if they have other employer-sponsored health insurance. By completing this form, employees can receive a monetary incentive for waiving their coverage. Understanding the requirements and process for this form can help employees make informed decisions about their health insurance options.

Open New York Ps 409 Editor Now
Content Navigation

More PDF Documents

Where to Mail Nys Tax Return - Locality information can also be detailed on the IT-2 form.

How to File a Response to a Summons - Transparency in the nature of the claim fosters a fair judicial process.

New York Parenting Plan - Parents must agree on terms outlined in the plan for it to be effective.

➤ New York Ps 409 PDF

Similar forms

  • PS-404 Enrollment Form: This form is used by employees to enroll in health insurance plans. Similar to the PS 409, it requires personal information and details about coverage. Both forms ensure that employees are properly enrolled in the appropriate health benefits programs.

  • Health Insurance Opt-out Program Guidelines: These guidelines outline the rules for opting out of health insurance coverage. Like the PS 409, they specify eligibility requirements and the process for employees to follow. Both documents aim to provide clarity on how employees can manage their health insurance options.

  • Qualifying Event Notification Form: This form must be completed by employees who experience a qualifying event that affects their health insurance. Similar to the PS 409, it requires timely reporting and documentation to ensure proper enrollment or changes in coverage.

  • Dependent Information Form: This document collects information about dependents who may be covered under an employee's health plan. Like the PS 409, it emphasizes the importance of accurate and complete information to maintain eligibility for benefits.

Guide to Filling Out New York Ps 409

Filling out the New York PS 409 form is a straightforward process that requires careful attention to detail. After completing the form, ensure it is signed and submitted alongside the necessary PS 404 Enrollment Form. This will allow you to participate in the Opt-out Program and receive the applicable benefits.

  1. Gather Necessary Information: Collect your personal details, including your name, address, date of birth, and telephone numbers.
  2. Marital Status: Indicate your marital status by checking the appropriate box.
  3. Agency Information: Fill in your agency name and address.
  4. Opt-out Election: Choose whether you are opting out of Individual or Family coverage by checking the corresponding box.
  5. Other Insurance Details: Provide information about your alternate employer-sponsored health insurance, including the name of the covered employee, their date of birth, Social Security Number, employer's name, and the effective date of the alternate coverage.
  6. Attestation: Read the attestation section carefully and confirm your understanding by signing and dating the form.