Home
Forms Library
PS-452 Application for Waiver of Premium - cs ny

PS-452 Application for Waiver of Premium - cs ny 2026

PS-452 Application for Waiver of Premium - cs ny Preview on Page 1

See details

4.9 out of 5

42 votes

The document is an application form (PS-452) for a waiver of health insurance premium contributions due to total disability, issued by the New York State Department of Civil Service. It outlines the eligibility criteria, including that enrollees on Family Medical Leave can apply, while those receiving short-term disability benefits cannot. The form requires completion by both the enrollee and their employing agency, as well as an attending physician's statement regarding the disability. It emphasizes confidentiality and provides contact information for further inquiries.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out PS-452 Application for Waiver of Premium - cs ny with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

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.

Start using our platform today to easily fill out your PS-452 Application for Waiver of Premium for free!

be ready to get more

Complete this form in 5 minutes or less

Get form

Security and compliance

At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.

Learn more

PS-452 Application for Waiver of Premium - cs ny 2026

Here's how it works

How to use or fill out PS-452 Application for Waiver of Premium - cs ny with our platform

Complete this form in 5 minutes or less

Related Searches

Security and compliance

Related links

Try more PDF tools