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 and UUP are not eligible to opt out of NYSHIP Health Insurance.
For the best experience in completing this form use a non-mobile device.
You may not be able to fill out this PDF form on your mobile device.
120 Crofts Hall
Form Type: Downloadable, PDF document
Requirements: Adobe Reader
Updated: November 2014
Owner: Human Resources