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Get and Sign Health Benefits Application Health Benefits Program 40 Rector Street 3rd Floor New York, NY 10006 212 5130470 TTYTDD 212 3 2017 Form

Get and Sign Health Benefits Application Health Benefits Program 40 Rector Street 3rd Floor New York, NY 10006 212 5130470 TTYTDD 212 3 2017 Form

Get the Health Benefits Application Health Benefits Program 40 Rector Street 3rd Floor New York, NY 10006 212 5130470 TTYTDD 212 3 2017 template, fill it out, eSign it, and share it in minutes.

Name qNon-City Related Does spouse/domestic partner have Non-City group health plan Is your spouse/domestic partner Medicare eligible qYes qNot Employed FAMILY INFORMATION Attach a second form if necessary dependent may not be covered under two NYC Health Plans. Enter change date if appropriate A. q New Enrollment B. Change of q Add Optional Benefits q Reinstatement q Waive Benefits q Spouse/Domestic Partner qAdd qDrop q Retirement EMPLOYEES ONLY Effective Date // q Disability Retirement q...
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