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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.

Blue Cross HMO Enrollment or Change Form (PDF)
HIP HMO and Choice Plus Enrollment Form (PDF)
HIP Vytra Enrollment Form (PDF)
HIP VIP Medicare Enrollment Form (PDF)
Buy Back Application (PDF)
NYSHIP Out of Network Claim Form (PDF)
Buy Back Instructions (PDF)
NYSHIP Disabled Dependent Form (PDF)
Smart Savings Reimbursement Form (PDF)
NYSHIP Statement of Dependence Form (PDF)
Smart Savings Procedures (PDF)
NYSHIP Health Insurance Transaction Form (PDF)
Change of Address Request Form (PDF)
Pre Authorization Agreement for ACH Debits (PDF)
Nassau County Authorization for Release of Health Information (PDF)
Documentation Required to Enroll Dependent(s) (PDF)
HMO Enrollees Statement of Dependence Form (PDF)
Young Adult Option Coverage (PDF)
HIP VIP Dis-enrollment Request Form (PDF)





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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