Health Benets Program
Application/Change Form
www.nyc.gov/olr
Employees
Return Form to:
Retirees (212) 513-0470
Return Form to:
For Domestic Partner
Changes - Return Form to:
Your Agency’s
Payroll or

Health Benefits Program
22 Cortlandt Street - 12th Fl.
New York, NY 10007
FAX: (212) 306-7756
Health Benefits Program 22
Cortlandt Street - 12th Fl.
New York, NY 10007
Attn: Domestic Partner Unit
Please print all information clearly using a black or blue ballpoint pen.
Applicant MUST check one:
q EMPLOYEE
q RETIREE
q RETURN TO RETIREMENT (Check this box if you were previously retired)
q LINE OF DUTY SURVIVOR
REASON(S) FOR SUBMISSION (Check one or more boxes. Enter change date, if appropriate)
A.
q
New Enrollment
q
Add Optional Benets*
B.
Change of:
C.
Transfer of Health Plan and/or
Optional/Benet Based on:
q
Reinstatement*
q
Waive Benets*
q Spouse/Domestic Partner: qAdd qDrop
q
Retirement EMPLOYEES ONLY: Effective Date: ______/______/______
q
Transfer Period
q
Disability Retirement*
q
Buy-Out Waiver Program
complete sections d, e, f & h
q Dependent Child(ren): qAdd qDrop q
Move Into/Out of Health Plan Area
q
Accident Disability Retirement
Effective Date: ______/______/______ Effective Date: ______/______/______
q
Drop Optional Benets*
q
Change of Name - Former Name:
q
Retiree Once-in-A-Lifetime
*Please indicate Effective Date: ______/______/______
____________________________________
Effective Date: ______/______/______
D. EMPLOYEE/RETIREE INFORMATION
Last Name: First Name: M.I.: Social Security Number or Employee ID Number:
- -
Home Address: Apt.: Pension Number:
City: State: Zip Code: Country (if outside the U.S.):
Date of Birth: Sex: Work - Telephone Number: Mobile\Home - Telephone Number: E-mail Address:
/ /
q
M qF
( ) - ( ) -
Marital
Status:
qSingle qMarried qDivorced
qWidowed qDomestic Partnership
Date of Event ( Agency in which employed or retired from: Union or Welfare Fund:
/ /
Name of current City Health Plan:
Are you Medicare eligible:
qYes qNo
If YES, please attach a copy of your Medicare card to this application.


E. SPOUSE/DOMESTIC PARTNER - ONLY COMPLETE IF YOUR SPOUSE/DOMESTIC PARTNER IS TO BE COVERED. IF NOT, LEAVE BLANK.
Last Name: First Name: M.I.: Social Security Number: Date of Birth:
- - / /
Sex: Is spouse/domestic partner:
qEmployed (Double City coverage is not permitted) qRetired (Double City coverage is not permitted) qNot Employed
qM qF
qCity Agency Name:__________________________________________________________________________ qNon-City Related
Does spouse/domestic partner have Non-City group health plan?
Is your spouse/domestic partner Medicare eligible:
qYes qNo
If YES, please attach a copy of his/her Medicare card to this application.


qYes qNo
F. FAMILY INFORMATION (Attach a second form if necessary; dependent may not be covered under two NYC Health Plans.)
List all eligible dependent children. Indicate if you are adding or dropping coverage by checking the appropriate box below.


*Attach a copy of Medicare card if
disabled dependent is Medicare eligible.
Dependent’s Last Name: Dependent’s First Name: Date of Birth: Social Security Number:
Sex:







/ / - -
q q q
/ / - -
q q q
/ / - -
q q q
/ / - -
q q q
/ / - -
q q q
G. HEALTH PLAN REQUESTED (Please print clearly)
FULL NAME OF HEALTH PLAN SELECTED: ____________________________________________________________________________________________________________

qYes qNo
H. EMPLOYEES ONLY (RETIREES ARE INELIGIBLE FOR THE HEALTH BENEFITS BUY-OUT WAIVER PROGRAM)


Employee Signature: Date:
I. TO PARTICIPATE IN THE HEALTH BENEFITS PROGRAM OR REQUEST CHANGES TO HEALTH COVERAGE


Furthermore, I agree that my periodic health plan deductions, if any, will be made on a pre-tax basis pursuant to the Internal Revenue Code 125. I understand that I have an option to


Employee/Retiree Signature: Date:
J. FOR COMPLETION BY PAYROLL OR PERSONNEL OFFICE ONLY



Agency Code: Title Code No.: Status: Appointment/Retirement Date: Pay Period: 
q Full-Time q Permanent q Weekly q Monthly
q Part-Time q Provisional
/ /
q Bi-Weekly q Semi-Monthly
/ /
Retirement System (For Retiring Employees): Years of Credited Service: City Start Date: Retirement Date: Pension Number:
/ / / /
Certifying Signature: Date: Telephone Number:
/ / ( ) -
h/olr/ehb/hba/2017 health benefits application.indd9/18
Print Form
Clear Fields

__________________________________________________________________
Section A: If you are a NEW retiree, you should only select from the following: Retirement, Disability Retire-

If you are already covered as a retiree, you should only select from the following: Drop/Add

(if you are requesting to reinstate your City coverage after having previously waived coverage).
Section B:
Check Spouse/Domestic Partner Information (Add/Drop) if you are adding or dropping a
spouse/domestic partner.

If you are dropping your spouse as a result of a divorce, you must attach a copy of the divorce
decree.
If you are adding a spouse, domestic partner or dependent child(ren) please refer to the SPD or
the Dependent Eligibility Required Documentation instructions on our Web site, at nyc.gov/hbp,

dependents.
Check Dependent Child(ren) Add or Drop if you are adding or dropping a dependent child.

documents proving guardianship or adoption.
If changing your name, please indicate your former name and provide documentation of name
change.
Section C 
Changing Plans) is being made during a Transfer Period.
Check Permanent Move Into/Out of Health Plan Area if you are requesting to change plans as a
result of either moving out of the service area of your current plan, or if you are moving into the
service area of another plan.

anytime other than a transfer period.
Section D:
If you are enrolled in Medicare Parts A & B, you must attach a photocopy of your Medicare card.
Section E: If you are married or have a domestic partner, this section must be completed only if you are
covering your spouse/domestic partner.
If your spouse/domestic partner is enrolled in health plan other than your City coverage or Medi-
care, you must indicate so.
If your spouse/domestic partner is enrolled in Medicare Parts A & B, you must attach a photo-
copy of his/her Medicare card.
Section F: List ALL eligible dependent children to be covered. If a dependent child is permanently
disabled, and on Medicare, you must attach a photocopy of his/her Medicare card. (CUNY


Section G: Write the complete name of your current health plan or the plan you are selecting (see back of
sheet). If you do not make an optional rider selection, you will be given basic coverage only.
Section H: This section is for employees only who wish to participate in the Buy-Out Waiver Program.
Remember to date your form. Retirees, Line of Duty Survivors and CUNY Adjunct
employees are not eligible for the Buy-Out Wavier Program.
Section I: 
Application/Change Form.
Section J: 
must complete this section.
See top, right-hand corner of reverse side for instructions on submitting this Application/Change Form.
Retain a copy for your records.



Aetna EPO
Cigna HealthCare
DC 37 Med-Team (DC 37 members only)
Empire EPO
Empire HMO
GHI-CBP/Empire BlueCross BlueShield
GHI HMO
HIP Prime HMO
HIP Prime POS
MetroPlus Gold
Vytra Health Plans
 Some health plans are only available in certain states and counties. Please
check the Summary Program Description booklet at www.nyc.gov/olr or call the health plans
directly.


Aetna Medicare PPO ESA Plan*
AvMed Medicare HMO* (Florida only)
Cigna HealthSpring Preferred with Rx (HMO)* (Arizona only)
DC 37 Med-Team Senior Plan (DC 37 Members Only)
Elderplan*
Empire Medicare Related Coverage
Empire MediBlue HMO*
GHI/Empire BlueCross BlueShield Senior Care
GHI HMO Medicare Senior Supplement
HIP VIP Premier (HMO) Medicare Plan*
Humana Gold Plus (certain counties in Florida)*
UnitedHealthcare Group Medicare Advantage Plan*
 Some health plans are only available in certain states and counties. Please
check the Summary Program Description booklet at www.nyc.gov/olr or call the health plans
directly.
* Medicare eligible retirees who wish to enroll in these plans must enroll DIRECTLY with the
health plan. Please verify with the health plan of your choice whether or not you reside in
its service area. Do not use this form for enrollment in these plans.