NYSHIP Health Insurance Enrollment or Change Form (PS-404)

State employees enroll or submit changes for NYSHIP health insurance.

Download the Form

Download the NYSHIP Health Insurance Enrollment or Change Form (PS-404)
Mobile Users

For the best experience in completing this form use a non-mobile device.

Using Firefox with PDF forms?

Make Adobe Acrobat the reader.

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

Read About Enrolling and Managing My State Benefits

To enroll family members include copies of:

For Spouse

 - Marriage Certificate

 - Birth Certificate

 - Social Security Card

 - If married more than 1 year proof of financial interdependance

For Children

 - Birth certificate

 - Social Security Card

Need Help Completing the Form?

For Active Employees

Nadine Burns.

Nadine Burns

Health Benefits Administrator

State Benefit Services

Phone: 716-645-4471

Email: nmburns@buffalo.edu

For Retiree Health Insurance Transactions

Lissa Jasinowski.

Lissa Jasinowski

Retirement Administrator

State Benefit Services

Phone: (716) 645-4488

Email: lmt22@buffalo.edu

Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: December 2014

Owner: State of New York Department of Civil Service