NYSHIP Health Benefits Opt-Out Election (PS-409)

During scheduled, announced periods, employees complete this form and the change form  (PS-404) to opt out of NYSHIP health insurance.

Employees represented by GSEU are not eligible to opt out of NYSHIP Health Insurance.

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Completing the PDF Form

  1. Read through all pages of the document to find specific instructions if any
  2. Enter requested information into the form
  3. Print the form
  4. Get required signatures
  5. Scan a copy of the signed form for your records
  6. Send the original, completed, signed form to:         

Human Resources
120 Crofts Hall
North Campus

Need Help Completing the Form?

Send email, phone or submit a question

Nadine Burns

Health Benefits Administrator

State Benefit Services

Phone: 716-645-4471

Email: nmburns@buffalo.edu

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Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: November 2014

Owner: Human Resources