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 and UUP are not eligible to opt out of NYSHIP Health Insurance.

Download the Form

Mobile Users

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

Also Complete

Using Firefox with PDF forms?

Make Adobe Acrobat the reader.

Using Mobile?

You may not be able to fill out this PDF form on your mobile device.

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
University at Buffalo
Townsend Hall
205 Hayes Road
Buffalo, NY 14214

Need Help Completing the Form?


UB HR Benefits

State Benefit Services

Phone: 716-645-7777

Email: ub-hr-benefits@buffalo.edu

Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: November 2014

Owner: Human Resources