Nys ebd 543 2026

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The document is an authorization form from the New York State Department of Civil Service, specifically for the Employee Benefits Division. It allows individuals to authorize the release of their protected health information related to the New York State Health Insurance Program (NYSHIP) and the New York Public Employee and Retiree Long Term Care Insurance Program (NYPERL). The form outlines who can authorize the release, what information can be disclosed, the purpose of disclosure, expiration terms, and includes sections for personal identification and signatures.

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Click ‘Get Form’ to open the NYS EBD 543 in the editor.
In Part A, enter the name and identification number of the individual whose information is being released. Ensure accuracy for proper processing.
Move to Part B and list the person(s) or organization(s) authorized to receive this information. Include full names and addresses for clarity.
In Part C, check the appropriate boxes to authorize the release of specific information maintained by EBD. You may also specify any limitations if necessary.
For Part D, indicate the purpose of disclosure by checking one of the provided options.
Complete Part E by specifying how long this authorization will remain effective. You can choose a specific date or event for expiration.
Finally, sign and date in Part F. If you are not the individual named, indicate your relationship and attach any required documentation.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (31 Votes)
2011	4.1 Satisfied (58 Votes)
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