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How to Change Health Carriers
Complete a PS-404 (Health Insurance Transaction Form)
*Form is available in the Office of Human Resources and on-line (accessible from theForms Center under Human Resources)
Form link: https://www.cs.ny.gov/forms/ps404.pdf
How to Complete Forms Required to Change Health Carriers
- Complete numbers 1-10
- On the reverse (or second page) complete number 14
- Sign and date under the Authorization section on the reverse (or second) page. All forms must be signed and dated.
- Send to the Office of Human Resources
Note: Doctor(s) information may be provided at a later date directly to the carrier.
**It is highly recommended your form be received by The Office of Human Resources at least two weeks prior to your new policy effective date.