Ps 457 2026

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The document is a form from the New York State Department of Civil Service that must be completed by an enrollee applying for health insurance coverage for a dependent child who is not their biological, adopted, or stepchild. It outlines eligibility criteria, including residency and support requirements, and provides instructions for submitting proof of support. The form also includes legal disclaimers regarding the accuracy of information provided and potential penalties for fraudulent claims.

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Click ‘Get Form’ to open the ps 457 in the editor.
Begin by filling out Part A, which includes your name, address, agency, and contact information. Ensure all details are accurate for smooth processing.
Next, provide your dependent's information including their name, health insurance ID number, and birth date. This is crucial for verifying eligibility.
Answer the questions regarding your relationship to the dependent and legal custody. Be honest and thorough as this impacts eligibility.
Indicate whether you have assumed responsibility for medical expenses by checking the appropriate box. This confirms your commitment to support the dependent.
Document the percentage of support you provide and attach any necessary proof such as tax returns or guardianship papers directly within our platform.
Finally, confirm that your home is the permanent residence of the dependent and specify how long this arrangement will last. Initial each response as required.

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Ps 457 2026

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Ps 457 2026

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