Nys form new york 2026

1. Click ‘Get Form’ to open the NYS Health Insurance Transaction Form for Retirees in the editor.
2. Begin by filling out the Employee Information section. Enter your first name, last name, middle initial, social security number, sex, street address, city, state, zip code, telephone number, and date of birth.
3. Indicate your marital status by checking the appropriate box and specify if you are covered under Medicare. Also, confirm if any of this information is new.
4. In the Enter Request(s) Below section, select your desired medical coverage options (individual or family) and indicate any changes or cancellations as needed.
5. Complete the Dependent Information section if applicable. Provide details for each dependent you wish to add or change coverage for.
6. Review all entered information for accuracy before signing and dating the authorization at the end of the form.

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