New York State Health Insurance Program Dependent Coverage

To submit this form, complete all required fields with accurate information and attach any necessary documentation. Ensure the completed form is sent to your agency Health Benefits Administrator via fax, mail, or email. For email submissions, use the following address: [insert email address] or fax to [insert fax number]. For physical mail, send to: Department of Civil Service, Albany, NY 12239. It is crucial to follow the submission guidelines to avoid any delays.

Important dates for this form submission will vary depending on individual circumstances and agency deadlines. It is advisable to check with your Health Benefits Administrator for specific timelines regarding application submissions. Ensure all dates align with the enrollment period for health insurance eligibility.

The purpose of the Statement of Dependence form is to establish eligibility for dependents under the New York State Health Insurance Program. It requires detailed information regarding the dependent's relationship to the enrollee and the support provided. This form ensures that dependents who meet the state's eligibility criteria can receive necessary health benefits.

• 1. Enrollee's Name: The full name of the individual applying for coverage.
• 2. Enrollee's Address: The residential address of the enrollee.
• 3. Dependent's Name: The name of the dependent child for whom coverage is being requested.
• 4. Health Insurance Identification Number: The identification number assigned for health insurance purposes.
• 5. Dependent's Birth Date: The date of birth of the dependent child.
• 6. Relationship to Dependent: The nature of the relationship between the enrollee and the dependent.
• 7. Legal Custody Information: The individual or agency with legal custody of the dependent.
• 8. Support Percentage: The percentage of support provided by the enrollee to the dependent.
• 9. Permanent Residence: Confirmation that the enrollee's home is the permanent residence of the dependent.

Failing to submit this form accurately can result in disapproval of your dependent's health coverage application. Missing or incorrect information could lead to delays and complications in obtaining necessary health benefits. It is crucial to adhere strictly to the completion guidelines outlined in the form.

• Disapproval of Application: Incomplete forms or inaccuracies can lead to rejection of your request.
• Delayed Benefits: Incomplete information may result in delayed access to health insurance for your dependent.
• Legal Issues: Providing false information can lead to potential legal consequences in terms of insurance fraud.

• 1. Adding a Child Dependent: Use this form to enroll children who live with you but are not your biological children.
• 2. Legal Guardianship: Necessary for legal guardians to secure health insurance for their dependents.
• 3. Domestic Partner Benefits: Required for applying for benefits for a partner's children in a domestic partnership.