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PS-452 Application for Waiver of Premium - cs ny 2026
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- Click ‘Get Form’ to open the PS-452 Application for Waiver of Premium in the editor.
- Begin by completing Part A. Fill in your name, health insurance ID number, date of birth, home address, and telephone number. Ensure all information is accurate.
- Next, proceed to Part B, which must be completed by your employing agency. This includes details such as the effective date of leave without pay status and health insurance coverage type.
- Leave Part C blank; this section will be filled out by United Health Care later.
- In Part D, your attending physician will need to provide their information and answer specific questions regarding your disability. Make sure they complete this section after Parts A and B are finalized.
- Once all parts are completed, save your document and send it to United HealthCare at the provided address.
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How to apply for a waiver of premium. To apply for a waiver of premium, obtain the Application for Waiver of Empire Plan Premium (PS-452) form from EBDRead more
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