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City of new york health benefits program 2026
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- Click ‘Get Form’ to open the Health Benefits Program Application/Change Form in the editor.
- Begin by selecting your status as either an Employee, Retiree, or Line of Duty Survivor in Section A. Make sure to check the appropriate box.
- In Section B, indicate any changes regarding your spouse or domestic partner. If applicable, provide necessary documentation such as a death certificate or divorce decree.
- Complete Section D with your personal information including your last name, first name, Social Security number, and contact details. Ensure all fields are filled clearly.
- If you have dependents, fill out Section F with their details and specify if you are adding or dropping coverage for each dependent.
- Review Sections G and H for health plan selection and optional benefits. Make sure to check the boxes that apply to you.
- Finally, sign and date the form in Section I to authorize your application or changes before submitting it through your agency’s payroll office.
Start using our platform today for free to streamline your health benefits application process!
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cty ny med b
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