Skip to Main Content

Loading

Loading
Nassau County, NY
Homepage
  1. Government
  2. Departments
  3. Residents
  4. Visit Nassau
  5. Business & Investor Relations
  6. e-Services
  7. Nassau A-Z
  1. Home
  2. Government
  3. County Comptroller
  4. Employee & Retiree Health Benefits
  5. Forms
  6. Active Employees Forms

Active Employees Forms

Active employees should contact their Department's Human Resources for all inquiries regarding health insurance.

Emblem Health VYTRA Enrollment Form (PDF)
BlueCross Blue Shield Enrollment or Change Form (PDF)
Buy Back Application (PDF)
Emblem Health HIP HMO Enrollment Form (PDF)
Buy Back Instructions (PDF)
NYSHIP Out of Network Claim Form (PDF)
Smart Savings Reimbursement Form (PDF)
NYSHIP Disabled Dependent Form (PDF)
Smart Savings Procedures (PDF)
NYSHIP Statement of Dependence Form (PDF)
Davis Vision Enrollment Form (PDF)
Flex Spending Account Health Care and Dependent Care Enrollment Form (PDF)
Dentcare Reimbursement Claim Form (PDF)
Documentation Required to Enroll Dependent(s) (PDF)
Dentcare Enrollment Form (PDF)
HMO Enrollees Statement of Dependence Form (PDF)
Domestic Partner Form (PDF)
Young Adult Option Coverage (PDF)
Change of Address Request Form (PDF)
NYSHIP Health Insurance Transaction Form (PDF)
Termination of Domestic Partnership
NYSHIP Dependent Tax Affidavit for Enrollment Form (PDF)
BlueCross Blue Shield Disabled Dependent Eligibility Form
Healthplex Claim Form
  1. Official Comptroller HeadshotElaine Phillips

    County Comptroller

    Subscribe to our Newsletter


    Contact Us
    Email the Comptroller's Office

    Contact Us Form

    Ph: 516-571-2386

    Nassau County Comptroller's Office
    240 Old Country Road
    Mineola, NY 11501






  1. Active Employees Forms
  2. Retiree and All Other Plan Enrollees Forms
  1. Home
  1. Accessibility
  1. Browser Support
  1. Copyright Notices
  1. Disclaimer
  1. Employment Opportunities
  1. Privacy Policy
  1. Site Map
  1. Contact Us
  1. Powered by CivicPlus®
/QuickLinks.aspx
Arrow Left Arrow Right
[]
Slideshow Left Arrow Slideshow Right Arrow