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.
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University at Buffalo
205 Hayes Road
Buffalo, NY 14214
Form Type: Downloadable, PDF document
Requirements: Adobe Reader
Updated: November 2014
Owner: Human Resources