NEW YORK STATE HEALTH INSURANCE TRANSACTION FORM


Last Name First MI. Enrollee�s Social Security No. 
Street Address Enrollee�s Sex 
Male FemaleCity State Zip Code 
Date of Birth Marital Status Single Married Widowed Divorced Date of Marriage 
/ / [ ] [ ] [ ] [ ] / / 
THIS SECTION TO BE COMPLETED FOR A CHANGE IN STATUS 
Change To Individual Coverage Reason: 
Date: / / 
(List Eligible Dependents Below) 
Change To Family Coverage Reason: Date: / / 
Last Name First MI. 
Change Name � Previous Name Was: Date: / / 
I Voluntarily Cancel My N.Y.S. Health Insurance SIGNATURE 
Cancellation For Myself and My Dependents X Date: / / 
IF YOU HAVE FAMILY COVERAGE, LIST ALL ELIGIBLE DEPENDENTS HERE 
Last Name First Name Date of Birth Relationship Social Security No 
Mo Day Yr Spouse Son Dtr S/Son S/Dtr L/G 
*Note: Child Relationship: Son-Son Dir -Daughter S/Son -Stepson S/Dir -Stepdaughter L/G -Legal Guardianship 
Other Health Coverage 
Is Your Spouse Employed? [ ] No [ ] Yes Name of Spouse�s Employer:_________________________________ 
Does Your Spouse Have Other Group Medical Coverage? [ ] No [ ] Yes 
Name of Carrier: ____________________________________________________________________________________ 
Are You Covered by MEDICARE? [ ] No [ ] A [ ] B -Effective Date:____________________________ 
Is Your Spouse Covered by MEDICARE? [ ] No [ ] A [ ] B -Effective Date:__________________________ 
Dependent Children Information 
Is There A Court Order For Health Coverage Responsibility? [ ] No [ ] Yes -Attach A Copy 
If There Are Stepchildren, Do They Reside With You? [ ] Yes [ ] No 
Signature: Date: