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Nassau County, NY
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  6. Retiree and All Other Plan Enrollees Forms

Retiree and All Other Plan Enrollees Forms

Retirees and all other enrollees should contact the Comptroller Health Benefits Division at ComptrollerHealthBenefits@nassaucountyny.gov or call (516) 571- 2369.

Emblem Health HIP VYTRA Enrollment Form (PDF)
Emblem Health HIP HMO Enrollment Form (PDF)
Buy Back Application (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)
Change of Address Request Form (PDF)
NYSHIP Health Insurance Transaction Form (PDF)
Nassau County Authorization for Release of Health Information (PDF)
Pre Authorization Agreement for ACH Debits (PDF)
HMO Enrollees Statement of Dependence Form (PDF)
Documentation Required to Enroll Dependent(s) (PDF)

Young Adult Option Coverage (PDF)
Domestic Partner Form (PDF)
NYSHIP Dependent Tax Affidavit for Enrollment Form (PDF)
Termination of Domestic Partnership



Contact Us

  1. Email the Comptroller's Office
    Ph: 516-571-2386

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


    Contact Us

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FAQs

  1. How do I determine if a vendor is already in the County’s master vendor file?
  2. How can a vendor be added to the County list?
  3. Can I make a change to a purchase order that has already been approved?
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