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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)
BlueCross Blue Shield Enrollment or Change 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)
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)
BlueCross Blue Shield Disabled Dependent Eligibility Form
Young Adult Option Coverage (PDF)
Domestic Partner Form (PDF)
NYSHIP Dependent Tax Affidavit for Enrollment Form (PDF)
Termination of Domestic Partnership
Healthplex Claim Form


  1. Official Comptroller HeadshotElaine Phillips

    County Comptroller

    Subscribe to the County Comptroller 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






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